etomidate

Editorial Team / Admin · Oct 17, 2003

Seems this is another evolving practice question. If the facility wants RNs to push, policy must be written after research done (involve pharmacy/anesthesia/ER docs/ER RNs -- and the state BON, for double-check on scope of practice??? just thinking aloud here . . .), and inservice given to RNs (and hopefully MDs).

In our cath lab the Anesthesiologist administers etomidate just for the testing of newly-implanted ICDs, before closing the pocket, for the same reasons named in other posts: VERY short half-life, low risk of apnea, little-to-no effect on BP or heart rate. Did I mention VERY short-acting??!!

Just some thoughts. Carry on. -- D

KKERRN · Oct 17, 2003

We use it for conscious sedation to reduce dislocations mostly.

We have policy and procedure to follow. We also use versed and sucs. Patient arouse better with the etomidate and seem to be discharged sooner than when we give versed.

avigail · Oct 17, 2003

Etomidate is great stuff, although those myoclonic movements can be a bit freaky. Our ER uses it for intubation (no ICP problems) and for reductions and bone setting. I do not administer the drug until the doc is at the bedside and ready to go. The great advantage of Etomidate is its rapid induction-about 1 minute- and short duration. Of course, never give it to a pregnant pt. Our ER uses Etomidate in children (hello tachycardia!) but its effects have not been studied. I think nursing drug guides should include a section on anaesthesia drugs used by ER/Trauma/critical care RNs; the IV drug guides do.

Of course, you should familiarise yourself with any drug you're giving. There's always the weighty PDR if you can't find an IV drug guide.

Anyway, I think Etomidate will win you over once you've spent 6 hours trying to titrate Diprivan or to wake somebody from a Fentanyl/Versed slumber.

Editorial Team / Admin · Oct 18, 2003

Good post avigail, sound thoughts.

eddmp · Oct 18, 2003

Yep use it all the time in CERTAIN ER's, depends on your hospital's policies... it works GREAT for conscious sedation for setting bones, relocating joints, intubation et al....I LIKE IT

kmchugh · Oct 23, 2003

OK, I'm sure to get flamed for this, but here goes. I know how tough you ED nurses are, I used to be one.

Yes, etomidate is a great drug. It has very good hypnotic properties, and as a general rule does not cause the hypotension and bradycardia some other induction agents can cause. It is ultra short acting, and can be very useful in the hands of someone familiar with it, and all the effects it can cause. HOWEVER, it is not without risks. There is a great potential to cause harm to a patient.

I know ER docs hate hearing this, but anesthetic agents should never be given by anyone not familiar with them, and by familiar I mean with anesthesia training and experience. Why? Because of the risks associated with all anesthetic agents. Lets look for a minute at this drug so many of you are so fond of.

Most anesthesia providers rarely, if ever, use etomidate. Many of the advantages you all see with it can be achieved through other drugs, with less side effects.

While it generally does not cause the hypotension that can be caused by propofol, for example, it can do so. Therefore, I wouldn't give it without having neosynepherine, ephedrine, and atropine all drawn up and also ready to give. The same holds true for apnea. Generally, etomidate won't cause this, but it can. Therefore, you need to have intubating materials at hand. At hand, not know where they are.

Etomidate also has a nasty reputation among those who have used it for inducing post anesthesia vomiting. Nasty enough that many of us know the drug as "vomidate." This effect is magnified when it is given in combination with a narcotic. Considering the fact that the only worse thing that can happen to a patient's lungs than aspiration of stomach contents is a shotgun blast to the chest, what are you going to do if your patient starts vomiting before his/her airway reflexes come back? I never extubate a patient induced with etomidate until they are awake and have intact reflexes. And I don't use etomidate as a sedation agent, the risks are too great.

Speaking of fentany, one of you mentioned that is a favored drug in your ED. Its a good drug, but did you know that you can induce chest wall rigidity so strongly with fentanyl that you will be unable to bag the patient? Better have sux at hand to treat this, and if you are going to give sux, better have intubation stuff at hand as well.

Literature lists the dose of induction of anesthesia for etomidate at 0.3 mg/kg. One of you said you find 20-30 mg to be a good dose to use in the ED. That's an induction dose for general anesthesia for most patients (66 to 100 kg patients). So, consider that when you administer that dose of etomidate, you are inducing general anesthesia.

Our ED where I now work does all these things as well, but they call for me or my partner to administer the medications and monitor the patients during the procedure. Not because we don't trust our ED nurses, we do. But because we don't think its right to force ED nurses to do the job we are uniquely trained, experienced and equipped to do.

Goodman and Gilmans The Pharmacological Basis of Therapeutics is one of the gold standard textbooks for teaching pharmacology. See if your hospital library has it, and look up some of the drugs you are giving. You might be surprised at the risks you are taking.

Kevin McHugh, CRNA

EastCoast · Oct 23, 2003

HI Kevin,

You should be in my facility when i have a difficult airway. Getting anesthesia (can't speak for the CRNA only the Anesthesiologist)

to respond without a huge song and dance is near impossible. If I assess the patient and realize the airway managment will require greater expertise I will always call the anesthesia people. However, i get such attitude it's ridiculous. What i find worrisome is the brand new docs who have really never had airway training (most specfically any pharmocology instruction) walking in and ordering succ.

V. Nightingale · Oct 23, 2003

We also use etomidate in the ED, and nurses push it, but it's never ever done without the doctor standing at the bedside, along with a third person who is present and ready to ventilate the patient if needed. Fortunately I've never had a patient experience adverse effects. *hee hee* The last patient I used it on woke up a few minutes later and snapped, "Well, are you going to set my (dislocated) shoulder or not?" What he didn't realize was that we'd not only reduced the dislocation, we'd already shot post reduction films without him knowing.

avigail · Oct 28, 2003

Actually, in my flight nurse life, I must say that etomidate is the preferred drug for RSI in the trauma pt. Of course, this seemed beyond the scope of the initial question. Kevin is very correct in stressing the need to know the ins and outs of any medication being administered (forgive me for repeating myself). That said, I have never had a pt vomit after etomidate. This may be due to the lower doses administered in ER or to lack of drug interactions. Nonetheless, I do not agree that anaesthesia drugs should only be given by the various forms of gas passers. I do believe that proper training and education is crucial for the limited use outside of OR settings.

Medic946RN · Oct 31, 2003

In the prehospital or transport arena I use it for rapid sequence intubation but in the ED it seems relegated to conscious sedation. If we're going to tube most docs prefer sux or nurcuron(sp?) along with a little versed.

Deaconess · Jan 12, 2004

Our protocol for RSI is Etomidate 20mg and Succinocholine 100mg. Post intubation we use vecuronium and/or propofol as necessary. For moderate/conscious sedation proceedures we use either propofol or versed. I've never seen Etomidate used for anything but RSI in our ER.

NYCRN16 · Jan 14, 2004

We use etomidate in the ER for intubation, usually 20 mg. I am allowed to push it (along with the sux), but I ONLY do it when the doctor is standing at the bedside with the tube and blade in his hand.