pgg

Laugh at me, will they?
Administrator
10+ Year Member
Dec 15, 2005
12,425
8,947
Not home
Status
Attending Physician
  • Like
Reactions: sethco
About the Ads

Ronin786

7+ Year Member
Mar 27, 2011
1,443
1,061
Status
Attending Physician

Ezekiel2517

Anesthesiologist
10+ Year Member
Jan 21, 2005
642
586
CA
Status
Attending Physician

SaltyDog

Perpetual Try-Hard Snarky B*tch
10+ Year Member
Aug 10, 2007
3,999
7,221
Closer to Mexico
Status
Attending Physician
I'm not sure why we are so concerned about these guys feeling any discomfort during execution. The constitution prohibits cruel and unusual punishment, not cruel or unusual punishment. I interpret that to mean that your execution method of choice can be just a cruel as you want it to be provided that it is the usual way you do it. Am I right??
 

PlutoBoy

Sic transit gloria mundi
Removed
7+ Year Member
Nov 19, 2009
15,505
10,054
I'm not sure why we are so concerned about these guys feeling any discomfort during execution. The constitution prohibits cruel and unusual punishment, not cruel or unusual punishment. I interpret that to mean that your execution method of choice can be just a cruel as you want it to be provided that it is the usual way you do it. Am I right??
No
 
  • Like
Reactions: nolagas
OP
pgg

pgg

Laugh at me, will they?
Administrator
10+ Year Member
Dec 15, 2005
12,425
8,947
Not home
Status
Attending Physician
Pharmacological capital punishment is one more infiltrated PIV from being lib-banned for good.
I can't find fault with their argument that if it can't be done competently, it shouldn't be done at all.

I'm anti capital punishment, but my opposition has less to do with pain and suffering (I think life in prison is worse), and more to do with cost and a judicial system that habitually convicts innocent people.


I was just morbidly amused that a drug I won't use in patients, because I think it might be poison, is now actually being used to kill people. Also, there aren't enough off topic threads on the forum at the moment.
 

Ronin786

7+ Year Member
Mar 27, 2011
1,443
1,061
Status
Attending Physician
I can't find fault with their argument that if it can't be done competently, it shouldn't be done at all.

I'm anti capital punishment, but my opposition has less to do with pain and suffering (I think life in prison is worse), and more to do with cost and a judicial system that habitually convicts innocent people.


I was just morbidly amused that a drug I won't use in patients, because I think it might be poison, is now actually being used to kill people. Also, there aren't enough off topic threads on the forum at the moment.
My distaste for Etomidate increased dramatically when I saw it has an off-label use for Cushing's for adrenal suppression. A drug that reliably knocks out your adrenals isn't something I want to use when there are much better options out there.
 

IkeBoy18

ASA Member
10+ Year Member
Jul 13, 2005
694
83
Status
Fellow [Any Field]
In the ICU i am in this month, everyone gets etomidate and sux for intubation. Around there they say that the adrenal suppression only lasts 24 hours if at all. I need to look into it more.
 

Robotic Wis-Hipple

Gold Donor
2+ Year Member
Feb 25, 2016
668
810
In the ICU i am in this month, everyone gets etomidate and sux for intubation. Around there they say that the adrenal suppression only lasts 24 hours if at all. I need to look into it more.
And it may, but adrenal suppression at the wrong time, like when an ICU pt needs to be intubated for instance, instead of just using propofol and supplementing the BP for a few minutes remains strange to me. It's odd to me that intensivists don't seem to be concerned. Yes, the data isn't inconclusive, and outcome differences for the most part have been attributed to the "well, those people are sicker" thought process, but I still find it weird that it's the primary induction agent everywhere but the OR.
 
About the Ads

IlDestriero

Ether Man
10+ Year Member
Nov 24, 2007
7,653
7,219
The ivory tower.
Status
Attending Physician
It'll be used up until somebody confuses the myoclonus for a painful response or suffocation.
Just push the paralytic first.


--
Il Destriero
 
OP
pgg

pgg

Laugh at me, will they?
Administrator
10+ Year Member
Dec 15, 2005
12,425
8,947
Not home
Status
Attending Physician
In the ICU i am in this month, everyone gets etomidate and sux for intubation. Around there they say that the adrenal suppression only lasts 24 hours if at all. I need to look into it more.
When the person pushing the induction drugs isn't comfortable bolusing vasopressors (as most non-anesthesia intensivists and EM docs aren't) then even I'll concede that etomidate is OK. It's better than MAPs of 30 post-intubation +/- an arrest and CPR until the one bolus they ARE familiar with (epi 1 mg per ACLS) gets administered.
 

MoMoGesiologist

What is dead may never die
2+ Year Member
Sep 17, 2016
451
542
Status
Attending Physician
I don't understand all the hate for etomidate. When youre called to intubate a sick patient in respiratory distress in the ICU, that you don't know too much about, high likelyhood catecholamine depleted, who knows their cardiac function or if pulmonary HTN (we have a not insignificant amount of those), and it's an RSI (so it's hard to titrate propofol to effect), and there is no aline, why not give the textbook safest, most CV stable, induction agent? If any unresponsive hypotension after, just give stress dose steroids.

If I'm worried someone is going to die on induction, I think etomidate is worth the possibility of adrenal suppression later. At least they're alive to experience it. It's a one time small dose, not an infusion. ED and medicine docs give it as their standard of care. Why does anesthesia dislike it so much? Why give propofol if you're worried someone will code on induction? Though maybe it's my inexperience speaking.
 

rakotomazoto

ASA Member
10+ Year Member
Aug 25, 2009
318
291
Southern California
Status
Attending Physician
Why give propofol if you're worried someone will code on induction?
These patients often do code on induction, in part due to the reduced sympathetic stimulation of breathing for their life until you sedate and intubate. Combine this with reduced preload from positive pressure ventilation and you've got a situation where coding on induction due to hypotension could happen regardless of what IV sedative you push. In that situation, many people want to use a medication that they use regularly and that they are very comfortable with. I have used etomidate from time to time, but I push some propofol just about every single day, so some might argue to just do what you know and also administer a pressor simultaneously on induction to counteract the propofol.

No matter how you get the tube in, you need to have pressors available, primed and connected to the patient, with the pump programmed as well as something to bolus via syringe. If that patient is really teetering on the edge, you need to be prepared to do battle.
 

Pooh & Annie

Member
10+ Year Member
Jul 15, 2005
1,374
572
Status
Attending Physician
I can't find fault with their argument that if it can't be done competently, it shouldn't be done at all.

I'm anti capital punishment, but my opposition has less to do with pain and suffering (I think life in prison is worse), and more to do with cost and a judicial system that habitually convicts innocent people.


I was just morbidly amused that a drug I won't use in patients, because I think it might be poison, is now actually being used to kill people. Also, there aren't enough off topic threads on the forum at the moment.
GD right. "Law and order" is VERY different than justice. The US kills poor people. That is all. Whether they're from the Ozarks, Flint, or Afghanistan, we will accept poor "collateral" for whatever ends we're looking to achieve.

This wouldn't make me so angry if I didn't love this country. If we don't recognize our [email protected] and try to fix them then there's nothing great about us.
 

dchz

Avoiding the Dunning-Kruger
Gold Donor
7+ Year Member
Sep 25, 2012
811
771
Unplugged
Status
Fellow [Any Field]
I don't understand all the hate for etomidate. When youre called to intubate a sick patient in respiratory distress in the ICU, that you don't know too much about, high likelyhood catecholamine depleted, who knows their cardiac function or if pulmonary HTN (we have a not insignificant amount of those), and it's an RSI (so it's hard to titrate propofol to effect), and there is no aline, why not give the textbook safest, most CV stable, induction agent? If any unresponsive hypotension after, just give stress dose steroids.

If I'm worried someone is going to die on induction, I think etomidate is worth the possibility of adrenal suppression later. At least they're alive to experience it. It's a one time small dose, not an infusion. ED and medicine docs give it as their standard of care. Why does anesthesia dislike it so much? Why give propofol if you're worried someone will code on induction? Though maybe it's my inexperience speaking.
Sorry to hijack the thread, but my thoughts are very similar.

And it may, but adrenal suppression at the wrong time, like when an ICU pt needs to be intubated for instance, instead of just using propofol and supplementing the BP for a few minutes remains strange to me. It's odd to me that intensivists don't seem to be concerned. Yes, the data isn't inconclusive, and outcome differences for the most part have been attributed to the "well, those people are sicker" thought process, but I still find it weird that it's the primary induction agent everywhere but the OR.
If it's an ICU pt under my personal care, supplementing BP for a bit is very reasonable. However, if it's an unknown pt that is purely in need of airway help, the supplement argument also works for glucocorticoids. no?

Sorry to turn your argument around on you, but:

Why not supplement the glucocorticoids/mineralcorticoids when the pt is more stable??

To drag this out more:

In non-etomidate situation: The intubator has to battle with immediate hemodynamic instability right around the time of intubation (read: unstable situation) and it has to be done by someone who has a lot of experience using pressors, it pretty much as to be done by an anesthesiologist (if we're lucky enough that it's only an after load problem, otherwise one'd have to diagnose preload/afterload/contractility in minutes). One's margin for error and the time frame in which you have to diagnose the problem is small.

In etomidate situation: The intubator intubates safely. in the next day or two, monitor their cortisol level and ANY PHYSICIAN has a window of 10-24 hours to do lab tests or decide to just stress dose/supplement a medium dose for safety's sake without much adverse effect to the patient. One's margin for error and time time frame to fix it is HUGE compared to the last scenario.
 
Last edited:

dhb

Member
Lifetime Donor
10+ Year Member
Jul 12, 2006
3,984
1,211
Status
Attending Physician
I don't understand people who use etomidate.
Why do self respecting anesthesiologists dislike it: it's an inferior product for 1st world care.
 

dchz

Avoiding the Dunning-Kruger
Gold Donor
7+ Year Member
Sep 25, 2012
811
771
Unplugged
Status
Fellow [Any Field]
You mean ketamine right?
In case you're not joking. ketamine increases catacholamine release, so if one has HR of 100+, ketamine is not the most CV stable drug around. ketamine also has a direct myocardial depressant effect (although some would argue this is purely theoretical and doesn't happen IRL), so if the pt is catacholamine deplete, ketamine is also not the most CV stable drug around (some would say ketamine is similar to thiopental in catacholamine deplete pts, some would say that's purely based on a dog study at abnormally high concentrations).

Regardless, those CV side effects are not found with an etomidate induction.
 
Last edited:

dchz

Avoiding the Dunning-Kruger
Gold Donor
7+ Year Member
Sep 25, 2012
811
771
Unplugged
Status
Fellow [Any Field]
I don't understand people who use etomidate.
Why do self respecting anesthesiologists dislike it: it's an inferior product for 1st world care.
Kindly explain to us why you think it's inferior for 1st world care.
 
About the Ads

FFP

Just another jerk
Gold Donor
10+ Year Member
Oct 17, 2007
7,834
8,157
Status
Attending Physician
Stop arguing about etomidate-induced adrenal insufficiency. It's so last decade. There is no difference in outcomes.
 

leaverus

New Member
15+ Year Member
Jan 23, 2004
593
162
Nowhere in particular
Visit site
Status
I don't understand all the hate for etomidate. When youre called to intubate a sick patient in respiratory distress in the ICU, that you don't know too much about, high likelyhood catecholamine depleted, who knows their cardiac function or if pulmonary HTN (we have a not insignificant amount of those), and it's an RSI (so it's hard to titrate propofol to effect), and there is no aline, why not give the textbook safest, most CV stable, induction agent? If any unresponsive hypotension after, just give stress dose steroids.
if the pt is that bad that I think even a little propofol will kill 'em, I give them something even better than etomidate: nothing.
 
  • Like
Reactions: nimbus

soorg

Board-certified maniac
10+ Year Member
Aug 7, 2008
203
126
The real issue here is how do you pronounce it: ee-tohm-idate or ee-tahm-idate??
 

WholeLottaGame7

10+ Year Member
Jul 10, 2005
2,004
1,123
Right here.
Status
Attending Physician
In etomidate situation: The intubator intubates safely. in the next day or two, monitor their cortisol level and ANY PHYSICIAN has a window of 10-24 hours to do lab tests or decide to just stress dose/supplement a medium dose for safety's sake without much adverse effect to the patient. One's margin for error and time time frame to fix it is HUGE compared to the last scenario.
That would be fine if that were the case. In real life, the super sick patient who you choose to use etomidate on because they have a tenuous BP to start out with, is going to crump (as others have mentioned) due to a combination of knocking out their sympathetic drive and the decreased preload from PPV. Basically every patient I used etomidate on in residency needed phenylephrine or epi post-intubation anyway, so what's the advantage? Might as well use something I know better. I don't think I've found a single scenario post-residency where I've been like "I really need etomidate about now."
 
  • Like
Reactions: Robotic Wis-Hipple

drmwvr

10+ Year Member
Dec 2, 2008
624
292
Status
Non-Student
Etomidate/propofol (50:50) induction means less of each and a very stable post induction patient. Actually a very gentle way to go. Very nice for GETA carotids.
 

dhb

Member
Lifetime Donor
10+ Year Member
Jul 12, 2006
3,984
1,211
Status
Attending Physician
Kindly explain to us why you think it's inferior for 1st world care.
You obviously more of a reader than a doer...
It's an inferior product that's all there is to it. If you can't deal with hypotension then do primary care.
 
Last edited:
Jun 8, 2016
26
21
Status
Attending Physician
In case you're not joking. ketamine increases catacholamine release, so if one has HR of 100+, ketamine is not the most CV stable drug around. ketamine also has a direct myocardial depressant effect (although some would argue this is purely theoretical and doesn't happen IRL), so if the pt is catacholamine deplete, ketamine is also not the most CV stable drug around (some would say ketamine is similar to thiopental in catacholamine deplete pts, some would say that's purely based on a dog study at abnormally high concentrations).

Regardless, those CV side effects are not found with an etomidate induction.
totally agree. When you're dealing with, say, critical aortic stenosis, you neither want to increase HR, nor would you want to decrease afterload. Yes, you could do propofol and play around with phenylephrine bolus and either under or over dose the Neo, or you could just push etomidate and BP stays rock stable. I always put in pre-induction A line for critical AS and I have yet to see one drop their BP from etomidate. If I intubate someone without knowing their full history, volume status, EF, +/- AS / MS / tamponade / whatever... etomidate is the way to go. Yes you should always have a pressor for rescue if needed, but instead of putting myself in a situation that might require pressor, I'd rather not put myself in that situation at all.
 
  • Like
Reactions: wickedskillz

FFP

Just another jerk
Gold Donor
10+ Year Member
Oct 17, 2007
7,834
8,157
Status
Attending Physician
That would be fine if that were the case. In real life, the super sick patient who you choose to use etomidate on because they have a tenuous BP to start out with, is going to crump (as others have mentioned) due to a combination of knocking out their sympathetic drive and the decreased preload from PPV. Basically every patient I used etomidate on in residency needed phenylephrine or epi post-intubation anyway, so what's the advantage? Might as well use something I know better. I don't think I've found a single scenario post-residency where I've been like "I really need etomidate about now."
That's because of this stupid myth that etomidate does not drop the blood pressure (and SVR). It does, just not as much as propofol, and it allows reflex tachycardia (hence a much lower drop in CO and BP). For sick patients, one should decrease the etomidate dose the same way one decreases the propofol dose.
 

AdmiralChz

ASA Member
10+ Year Member
Sep 8, 2008
3,392
2,869
Mid-Atlantic
Status
Attending Physician
In residency the attendings treated etomidate much like those on this thread, with fear and avoidance. But it was largely institutional, when we'd get faculty who trained elsewhere theyd laugh and grab for the clear stuff.

I use etomidate almost everyday in fellowship with mega sick cardiac patients. Somehow, none of them have been crashing on day 2 or 3 from adrenal insufficiency. just my personal anecdotes, it has completely changed my approach to induction.
 
Last edited:
  • Like
Reactions: WheezyBaby and dchz

psychbender

Cynical Member
Lifetime Donor
10+ Year Member
Jan 19, 2005
2,215
1,186
37
Nowhere, nowhere at all...
Status
Attending Physician
totally agree. When you're dealing with, say, critical aortic stenosis, you neither want to increase HR, nor would you want to decrease afterload. Yes, you could do propofol and play around with phenylephrine bolus and either under or over dose the Neo, or you could just push etomidate and BP stays rock stable. I always put in pre-induction A line for critical AS and I have yet to see one drop their BP from etomidate. If I intubate someone without knowing their full history, volume status, EF, +/- AS / MS / tamponade / whatever... etomidate is the way to go. Yes you should always have a pressor for rescue if needed, but instead of putting myself in a situation that might require pressor, I'd rather not put myself in that situation at all.
If you're not seeing hypotension from etomidate inductions, you're either not looking, or you're decreasing the dose. My two other colleagues on my old hospital's CT team insisted on etomidate for all cardiac inductions, pushed 20mg on everyone, and pressure dropped every time. I saw the same in residency from attendings who were similarly dogmatic in insisting that all "sick" patients be induced with etomidate, then slamming in the full 0.2-0.3mg/kg. The hypotension didn't look as severe as with 2mg/kg propofol, but I don't push that much at once in anybody at once, anyway. When I first got to my old hospital, and didn't want to buck the system, I used etomidate, but decreased the dose. Often, 6-10mg on top of the little fent and midaz from preinduction CVC placement (our other institutional peculiarity) was sufficient, and very stable. Ultimately, I switched to ketamine/propofol (around 0.5mg/kg each), and see similar hemodynamics, but markedly reduced opiate use from the ketamine up front. In the past, I avoided etomidate because of fear of adrenal suppression, because I saw a whole ONE case of it, but now I don't use etomidate simply because I found an alternative that I like better, and fail to see what etomidate adds to my induction and anesthetic plan.
 
About the Ads

Laryngophed

Supratentorial problems
10+ Year Member
Sep 4, 2007
2,692
892
TDC
Status
Fellow [Any Field]
It's not the wand, it's the wizard.

Sent from my SM-G930V using Tapatalk
I like this so hard.

Because I like to teach I get a lot of medical student, off-service residents (read ER residents), and juniors in my program. I try, again and again, to beat them over the head with this phrase - "sick people do not need a full stick of anything." And for the ER residents I remind them that 20mg of etomidate and 100mg of succinylcholine isn't a standard dose for any reason other than that is what comes in the vials available to the ED.
 
  • Like
Reactions: nimbus

Nephro critical care

5+ Year Member
Feb 4, 2014
228
129
Status
Fellow [Any Field]
Etomidate or propofol/ketamine depends upon who is intubating whether anesthesia or CC or ED. Personally as a CC attending I prefer etomidate. I don't intubate nearly as much as an anesthesiologist and while I intubate 95% of my pts myself without anesthesia backup it's always at the back of my mind that I may not be able to intubate my next pt. So I don't want my pt to be hypotensive during intubation as I don't want to deal with a hemodynamic code while I am mucking around with their airway. As CC we deal with adrenal suppression all the time and I won't lose sleep over hydrocortisone 100 mg IVq8hrs for 48 hrs.
Uptodate recommends etomidate in most patients in whom post procedure hypotension is anticipated. Etomidate is also recommended for cardiovascular pts who may have an adverse reaction to the sympathomimetic effects of ketamine or brain injury pts who won't take kindly to hypotension from propofol or to the ICP raising effects of ketamine. Yes , a status asthmaticus may do better with bronchodilatory effects of ketamine and you may choose it for an awake intubation but I believe the default should be etomidate.
I can't recall where I got this statistic but 70% of ICU intubations in the USA are performed using etomidate.
 
Last edited:
Jun 8, 2016
26
21
Status
Attending Physician
If you're not seeing hypotension from etomidate inductions, you're either not looking, or you're decreasing the dose. My two other colleagues on my old hospital's CT team insisted on etomidate for all cardiac inductions, pushed 20mg on everyone, and pressure dropped every time. I saw the same in residency from attendings who were similarly dogmatic in insisting that all "sick" patients be induced with etomidate, then slamming in the full 0.2-0.3mg/kg. The hypotension didn't look as severe as with 2mg/kg propofol, but I don't push that much at once in anybody at once, anyway. When I first got to my old hospital, and didn't want to buck the system, I used etomidate, but decreased the dose. Often, 6-10mg on top of the little fent and midaz from preinduction CVC placement (our other institutional peculiarity) was sufficient, and very stable. Ultimately, I switched to ketamine/propofol (around 0.5mg/kg each), and see similar hemodynamics, but markedly reduced opiate use from the ketamine up front. In the past, I avoided etomidate because of fear of adrenal suppression, because I saw a whole ONE case of it, but now I don't use etomidate simply because I found an alternative that I like better, and fail to see what etomidate adds to my induction and anesthetic plan.
This may be a side issue, but ketamine at my hospital always comes in a 500mg vial and locked up as a controlled substance. Always a nuisance having to find someone to waste it or, before the days of OR Pyxis, have to find a nurse just to get it -- not an ideal situation in an emergency. I use 0.2 mg/kg, with very little fentanyl, if at all, and gentle PPV prior to intubation, like 5-10 cm H2O. A lot of sick preload dependent pt, aggressive PPV can easily drop the BP.
 

Hawaiian Bruin

Breaking Good
15+ Year Member
Mar 13, 2003
2,156
1,088
Visit site
Status
Attending Physician
I induce every heart I do with ketafol. Doses depend on how sick. Haven't used etomidate since 2011. Not even once.

That said, I do think that its danger is a little overblown. If it was murdering people left and right, we'd know about it.

What I do take issue is the idea that a patient in extremis will have unchanged hemodynamics if given etomidate and then PPV.

They won't. They'll tank. Seen it a hundred times, and everyone always acts surprised. I can't stand this "20 etomidate 100 sux for all comers" business that apparently gets taught in EM residency and critical care fellowships around the country, but whatever. I don't use it, but you're welcome to.

I'll take this opportunity to disabuse those residents out there who are still being taught not to give ketamine to CABG patients of the notion that this is good teaching.

When given as part of a "balanced" induction (a little midaz, a little fent, a little prop), the heart rate does not change one little bit. Even better, the patient doesn't get tachy during laryngoscopy.

If you give some ketamine and nothing else to an awake person, yes they'll get tachy. Because they're tripping out. Pink elephants and out of body experiences make your heart rate go up.

But not as part of an anesthetic induction. I give it to every CABG I do. Zero percent of them get ischemic from ketamine.
 

Arch Guillotti

Senior Member
Staff member
Administrator
Lifetime Donor
15+ Year Member
Aug 8, 2001
7,750
1,555
Status
Attending Physician
I like etomidate for ICU intubationso_O. Quick, dirty and easy.

Nobody has ever crumped on me and coded after etomidate and unfortunately I can't say the same even for very small titrated propofol doses.

20 mg of etomidate may crump a patient. Much less does the trick sometimes.
 

MoMoGesiologist

What is dead may never die
2+ Year Member
Sep 17, 2016
451
542
Status
Attending Physician
Nobody has ever crumped on me and coded after etomidate and unfortunately I can't say the same even for very small titrated propofol doses.
What's the smallest dose of propofol you've given and seen someone code? Could it have been avoided if you gave something else?
 

wickedskillz

ASA Member
7+ Year Member
Jun 9, 2011
175
49
Status
Resident [Any Field]
good luck when you push prop on an icu patient and your backup plan is norepi but low key their pH is 7.03. And how about intubating post-stroke patients for angiograms/thrombectomy, when you have set bp targets and hypotension = brain / loss of function. During anesthesia residency i barely ever used etomidate, but during my icu fellowship now i kind of see the wisdom. i would rather spend the 3-5 minutes writing the intubation note than supporting their pressure.
 

FFP

Just another jerk
Gold Donor
10+ Year Member
Oct 17, 2007
7,834
8,157
Status
Attending Physician
good luck when you push prop on an icu patient and your backup plan is norepi but low key their pH is 7.03. And how about intubating post-stroke patients for angiograms/thrombectomy, when you have set bp targets and hypotension = brain / loss of function. During anesthesia residency i barely ever used etomidate, but during my icu fellowship now i kind of see the wisdom. i would rather spend the 3-5 minutes writing the intubation note than supporting their pressure.
You need a better ICU fellowship. Just kidding. :p

If you push the norepi first, then push the propofol once the SBP is high, you will both know the patient's response to norepi boluses and have an extra margin of safety. Also, with propofol, it's definitely about the wizard. I never start with more than 1 mg/kg in a critical patient, and that gets adjusted downwards with age and severity of illness. Slow controlled induction is seldom more important than with a sick patient who has limited cardiovascular reserves.

In my book, any anesthesiologist worth his/her salt should know how to induce anybody with anything (unless there is some specific contraindication to a drug - i.e. I wouldn't use propofol to maintain spontaneous ventilation for a difficult airway). I have seen people intubated with just a lot of versed. Most of us who couldn't care less if etomidate didn't exist, have gone through etomidate shortages when we learned to use something else instead. Same for those of us who can intubate with no sux or just low doses of sux etc. There is more than one way to skin the cat, and we should master as many as possible.
 
Last edited:
Mar 11, 2017
21
15
Back to the original theme of this thread...a good IV and a heavy-handed standard GA induction (without ventilation/intubation) would work and there'd be no perceived discomfort.


Sent from my iPhone using SDN mobile
 

Laryngophed

Supratentorial problems
10+ Year Member
Sep 4, 2007
2,692
892
TDC
Status
Fellow [Any Field]
You need a better ICU fellowship. Just kidding. :p

If you push the norepi first, then push the propofol once the SBP is high, you will both know the patient's response to norepi boluses and have an extra margin of safety. Also, with propofol, it's definitely about the wizard. I never start with more than 1 mg/kg in a critical patient, and that gets adjusted downwards with age and severity of illness. Slow controlled induction is seldom more important than with a sick patient who has limited cardiovascular reserves.

In my book, any anesthesiologist worth his/her salt should know how to induce anybody with anything (unless there is some specific contraindication to a drug - i.e. I wouldn't use propofol to maintain spontaneous ventilation for a difficult airway). I have seen people intubated with just a lot of versed. Most of us who couldn't care less if etomidate didn't exist, have gone through etomidate shortages when we learned to use something else instead. Same for those of us who can intubate with no sux or just low doses of sux etc. There is more than one way to skin the cat, and we should master as many as possible.
I'm still just a resident, but I've also intubated critically ill patients with a little midazolam. I am with everyone else here, when you aren't well, it takes very little to push you over the edge. And never discount the amnesia/anesthesia provided by critical illness/comorbidities.

And I was taught a very hard lesson in respecting all induction drugs. Yes, there are small studies that show that etomidate has a more hemodynamically favorable profile over propofol in typical induction doses. But it can absolute drop the bottom out on someone. I have seen an arrest after etomidate administration, dose adjusted for illness. It sucks just as bad as an arrest from propofol or any other drug.
 
  • Like
Reactions: WheezyBaby

sethco

Senior Member
15+ Year Member
Dec 12, 2003
1,150
257
40
Status
Attending Physician
Like HB, my current practice is heavy in Cardiac. Lots of sick peeps. Redo Valves, EF<20%, high grade LM disease, Dissection, Septic Endocarditis, VADs, etc. Haven't used Vomidate since 2nd year of residency. Have found I can use a smaller dose of Propofol, as part of a balanced induction, and still maintain hemodynamic stability. My usual practice with the moderately sick (think EF 25-30% with severe AS) is to go lighter on the Propofol and heavier on the benzos. Sicker patients, I might not do any hypnotic agent, just the benzos, low dose fentanyl, +/- volatile agent. In fellowship, they liked to use Diazepam. I don't have access to that or Ketamine at most of my hospitals, so I use a larger dose of Midazolam. Preinduction Arterial lines for about 50% of my patients. Haven't had to "code" a patient post induction in almost 5 years of doing solo practice, primarily consisting of cardiac patients. I completely agree with those that say the choice of drug is less important than how that drug is used by the person administering it. I just don't like the side effects of Etomidate compared to its "potential" benefits over other available drugs
 
OP
pgg

pgg

Laugh at me, will they?
Administrator
10+ Year Member
Dec 15, 2005
12,425
8,947
Not home
Status
Attending Physician
In residency the attendings treated etomidate much like those on this thread, with fear and avoidance. But it was largely institutional, when we'd get faculty who trained elsewhere theyd laugh and grab for the clear stuff.

I use etomidate almost everyday in fellowship with mega sick cardiac patients. Somehow, none of them have been crashing on day 2 or 3 from adrenal insufficiency. just my personal anecdotes, it has completely changed my approach to induction.
I think I used etomidate 3 or 4 times total my entire fellowship year. When an attending told me to. Same sick population of cardiac cripples.

I just ... don't see any place for it in the OR. Those patients who are truly on the edge of their reserve go to sleep just fine with a bit of midazolam, 0-20 of propofol, and a whiff of gas. Sometimes a little ketamine. I genuinely can't think of a single case where I would want to use it.
 
About the Ads