Etomidate Vs. Propofol for Standard Inductions of GA

[jfratian, DNP, RN, CRNA]

I think the spirit of this post is routine use and not niche scenarios.   Etomidate seems pretty uncommon for routine inductions and 3 textbooks I cited advise against it.  I can't find any metanalysis that support its routine use.  Propofol seems pretty safe and is widely used. We also have ketamine...widely used for trauma inductions.  Do you have any citations to back up routine use of etomidate over propofol or ketamine?

[offlabel]

Don't know why someone would choose etomidate over propofol routinely.

[BigPappaCRNA]

I have not used Etomidate in more than 10 years.  Just see no reason for it.  The adrenal suppression is well documented.  Now, where there may be some area for discussion is in the clinical significance of the adrenal suppression.  That is open to debate.  I use Propofol now for almost any clinical situation.  Just cannot imagine a clinical scenario that would make me choose Etomidate over Propofol.  The emesis producing effects of Etomidate alone, make me hesitant to even consider it.

Forgot to mention, I cannot for the life of me, figure out why a provider would ever split up and dose Etomidate and Propofol 50/50.  I have seen it done, but no provider has ever given me a cogent rational for doing so.

[jfratian, DNP, RN, CRNA]

This is from APEX.  I'd avoid.  Why not do a ketamine induction instead?  

[offlabel]

5 hours ago, jfratian said:

This is from APEX.  I'd avoid.  Why not do a ketamine induction instead?  

Association is not causation, I.e. is the morbidity 2/2 the reason that etomidate was chosen in the first place? Propofol isn't an agent chosen very often in very sick/high risk heart. Read the studies, then decide. I wouldn't hesitate to use etomidate in a sick heart. 

[jfratian, DNP, RN, CRNA]

Correct, but the original post was talking about non-cardiac inductions with etomidate or a prop/etomidate mix.  Not sure how the heart example applies?

[offlabel]

2 hours ago, jfratian said:

Correct, but the original post was talking about non-cardiac inductions with etomidate or a prop/etomidate mix.  Not sure how the heart example applies?

I bled cardiac induction into my thought, but the principle still carries....patients with higher risk for morbidity and mortality tend to get etomidate and don't do well independent of a one time dose of the drug. Just because someone is going to sleep for a 'non-cardiac' procedure doesn't mean they can't have reduced EF, CADz, valvular dz, whatever. A big difference in these types of patients undergoing a non-cardiac procedure is that their cardiac problem is not being fixed so it wouldn't be unreasonable  to expect an even higher morbidity and mortality. Etomidate has its place and the bias against it is really naïve, IMO.

[offlabel]

I don't know what the argument here is. If ASA 4 and 5 patient's are 'routine' then routine etomidate use is defensible.  Niche scenarios? These are every single day scenarios. Just asking...how many patients do you put to sleep for surgery in a week?

Ketamine, while useful, is  not a hypnotic. It has gotten an almost mythical standing outside of anesthesia circles because it is a different drug at different doses and non anesthesia providers don't use it in it's full spectrum. People can and do tank with ketamine inductions. 

[Tegridy]

that would be a hard sell saying that the increased 30 day mortality is due to a one-time slap of etomidate....