Etomidate ========= þ for Pediatric anaesthesia - for kids greater than 10 years old: 0.3 mg/kg (0.2-0.6 mg/kg) which is same as for adults - this produced good results in 59% of kids 6-15 yrs old and fair results in 39% [Kay B. A clinical assessment of the use of Etomidate in children. Br J Anaesthes 1976;48:207-211.] but the author suggested using 0.3mg/kg if not adding an analgesic to it. - the rectal dose is 6.5 mg/kg (20 times the IV dose) [Linton DM, Thoington RE. Etomidate as a rectal induction agent. SA Med J 1983;64:309-310.] þ Etomidate prehospital 1/ In France, and especially in Paris and its area, the recommended protocol associates Etomidate and Suxamethonium. The reference is in french, and here is the abstract: RAPID SEQUENCE INDUCTION FOR PREHOSPITAL ENDOTRACHEAL INTUBATION The choice of sedation for emergency intubation remains controversial. This lack of concensus has led to various sedation protocols used in French prehospital care setting. A review of data from the litterature suggests that the association etomidate - suxamethonium is probably the best choice for rapid sequence intubations in the prehospital settings. Its benefits include protection against myocardial and cerebral ischaemia, decreased risk of pulmonary aspiration, and a stable haemodynamic profil. Randomized studies are needed to substantiate the advantages of the association etomidate - suxamethonium for rapid sequence intubation in the prehospital setting. You will find the references of the article in which you can find up to 105 references, their reviewed data - base. Adnet F. and coll.: Induction anecth‚sique en s‚quence rapide pour l'intubation trach‚ale pr‚hospitaliŠre. Ann Fr Anesth R‚anim 1998; 17 : 688 - 98. þ Etomidate and Cortisol Suppression > >Etomidate is the appropriate induction agent for a head injury - it > > >helps the brain when there is intracranial pressure increase and it > > >reduce brain metabolism. > > Same for thiopentone and probably propofol. Etomidate reduces > cortisol > secretion and this effect on morbidity/mortality (if any) has not > been > quantified. Some would argue that etomidate is an extremely poor > choice for > this reason. Again, no good evidence for any agent over any other. Simon, There is some stuff in the anesthesia literature that would suggest that the suppression of cortisol probably is clinically insignificant, at least in the patient populations examined. Below I have included two articles that support this hypothesis. We love the stuff in our institution (well, some of us do ;>) because of the haemodynamic stability that that agent seems to have. I do really agree with the last line, I have found no great evidence for one hypnotic/sedative over the other as an induction agent in RSI. Ye gods, I can't believe that I'm putting medline abstracts on the net :{} article 1 Authors Crozier TA. Schlaeger M. Wuttke W. Kettler D . Institution Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Georg-August Universitat Gottingen. Title [TIVA with etomidate-fentanyl versus midazolam-fentanyl. The perioperative stress of coronary surgery overcomes the inhibition of cortisol synthesis caused by etomidate-fentanyl anesthesia]. [German] Original Title TIVA mit Etomidat-Fentanyl versus Midazolam-Fentanyl. Der perioperative Stress der Koronarchirurgie uberwindet die Kortisolsynthesehemmung nach einer totalen intravenosen Anasthesie mit Etomidat-Fentanyl. Source Anaesthesist. 43(9):605-13, 1994 Sep. NLM Journal Code 4my Local Messages Back volumes may be available in the Carpenter Library Country of Publication Germany Abstract Etomidate is a hypnotic with only minor effects on haemodynamics. Although its rapid elimination kinetics would suggest its use in total intravenous anaesthesia (TIVA) and sedation, its administration in higher doses or for a prolonged period has been discouraged due to its inhibitory effects on corticosteroid synthesis. Newer evidence that the suppression of cortisol synthesis might not be total requires a re-evaluation of this drug as a component of a TIVA technique. The effects of high-dose etomidate with fentanyl on spontaneous and stimulated corticosteroid levels as a measure of the magnitude and duration of adrenocortical suppression, as well as on plasma concentrations of adrenocorticotropic hormone (ACTH) beta-endorphin, and catecholamines during cardiac surgery were investigated in a prospective, randomised study and compared to those following the administration of midazolam-fentanyl. PATIENTS AND METHODS: Nineteen patients undergoing myocardial revascularisation were assigned to two groups: group 1: etomidate-fentanyl (n = 9) and group 2: midazolam-fentanyl (n = 10). Anaesthesia was induced with fentanyl 0.5 mg and either etomidate 0.3 mg/kg or midazolam 0.2 mg/kg. Relaxation was achieved with pancuronium 0.1 mg/kg. Anaesthesia was maintained during extracorporeal circulation (ECC) with an infusion of etomidate (0.36 mg.kg-1.h-1) or midazolam (0.16 mg.kg-1.h-1) and fentanyl 10 micrograms.kg-1.h-1. Blood samples were drawn before induction, before ECC, and 1, 6, and 20 h after surgery. Cortisol secretion was stimulated with 0.25 mg ACTH1-24 IV at 6 and 20 h postoperatively. RESULTS: The total drug doses were etomidate 87 +/- 3 mg and midazolam 46 +/- 2 mg. Plasma cortisol concentrations decreased in the etomidate group from 20 (10-31) to 10 (6-31) micrograms.dl-1 (median and range) before ECC, but had returned to baseline at 1 h and were significantly increased at 6 h [29 (15-47) micrograms.dl-1] and 20 h [46 (29-62) micrograms.dl-1]. There was no difference between the groups except at 20 h, when cortisol levels were higher in the etomidate group. The stimulated cortisol increase was markedly impaired in this group at both measuring points. ACTH and beta-endorphin were markedly increased in the etomidate group and ACTH concentrations were eight times greater than the corresponding values in the midazolam group after surgery (ACTH 141 vs. 18 pmol.l-1). Plasma catecholamine concentrations increased significantly in both groups. Noradrenaline concentrations were greater in the etomidate group at 6 h after surgery. Two patients in the midazolam group and none in the etomidate group required circulatory support with exogenous catecholamines. DISCUSSION: It is concluded that the stress of cardiac surgery can overcome the block in cortisol synthesis caused by the administration of high-dose etomidate by substantially increasing ACTH secretion. The administration of high-dose etomidate was not associated with cardiovascular instability. The use of etomidate as a component of TIVA can therefore not be ruled out on the grounds of insufficient cortisol secretion. article 2 Authors Vanacker B. Wiebalck A. Van Aken H. Sermeus L. Bouillon R. Amery A . Institution Department of Anaesthesiology, University Hospitals, Katholieke Universiteit Leuven, Belgium. Title [Quality of induction and adrenocortical function. A clinical comparison of Etomidate-Lipuro and Hypnomidate]. [German] Original Title Induktionsqualitat und Nebennierenrindenfunktion. Ein klinischer Vergleich von Etomidat-Lipuro und Hypnomidate. Source Anaesthesist. 42(2):81-9, 1993 Feb. NLM Journal Code 4my Local Messages Back volumes may be available in the Carpenter Library Country of Publication Germany Abstract The purpose of this study was to compare etomidate in a lipid emulsion (Etomidat-Lipuro; Braun, Melsungen) and in propylene glycol (Hypnomidate, Janssen Pharmaceutica) in 90 patients in terms of anaesthetic induction characteristics with special reference to injection side effects, haemodynamic changes, and quality of induction. Adrenocortical hormones were determined in 30 patients who received either Etomidat-Lipuro, Hypnomidate, or propofol (Diprivan, ICI Pharma) for induction of anaesthesia. METHODS: One hundred twenty patients gave their informed consent to the study. In the first part, 90 patients were assigned at random to two groups in which induction of anaesthesia was performed either with Etomidat-Lipuro or Hypnomidate. Anaesthesia was started by i.v. injection of 25 micrograms/kg alfentanil (Rapifen, Janssen Pharmaceutica). One minute later, the hypnotic agent was injected into a freely running i.v. line (18 Gcannula) that was used only for the hypnotic and was removed 15 min later. During injection, the patients were asked to inform the anaesthesiologist spontaneously and on request about their sensations at the injection site. The time from the beginning of anaesthesia until the disappearance of the eyelash reflex was measured. The patients were ventilated and vecuronium was administered to allow good intubation conditions 2-3 min later. For the first 10 min, blood pressure and heart rate were measured every minute. Postoperatively, the same investigator made rounds once a day and examined the injection sites. Signs of pain, redness, swelling, induration, thrombophlebitis, or thrombosis were noted. In the second part of the study, 30 patients were investigated for endocrinological changes after induction of anaesthesia with Etomidat-Lipuro, Hypnomidate, or Diprivan. The patients were allocated to the groups at random. A radial artery catheter was inserted in every patient. Sampling took place 30 min before and 1 and 2 h after induction. Additional samples were drawn 30 min and 1, 2, and 22 h after i.v. administration of 0.25 mg ACTH (Synacthen, Ciba-Geigy). The plasma concentrations of cortisol, 17 alpha-OH-progesterone, and aldosterone and the renin activity were determined by high-performance liquid chromatography. RESULTS: The loss of the eyelash reflex occurred 42.9 +/- 8.7 and 42.2 +/- 11.0 s after the administration of Etomidat-Lipuro and Hypnomidate. The haemodynamic changes were minimal in both groups. After administration of alfentanil, local side effects of the hypnotics were scarce, with a tendency to be weaker and more seldom after Etomidat-Lipuro (3/55 versus 8/55). The postoperative vein reactions were generally mild and occurred in 17 out of 55 patients after Etomidat-Lipuro and 15 out of 55 patients after Hypnomidate. In most cases these signs were no longer present on the 2nd day after the procedure. Cortisol levels were depressed initially by all the hypnotic drugs used. While there was spontaneous recovery in the Diprivan group after 2 h combined with a positive overshooting response to ACTH stimulation, in the etomidate groups cortisol could not be stimulated; it normalized slowly during the following 24 h. The 17 alpha-OH-progesterone increase was significant in the etomidate groups after the administration of ACTH. The aldosterone levels decreased after etomidate injection and had not normalized 24 h later, while there was a normal response to ACTH in the propofol group. There was a normal decrease in renin activity in all three groups after the administration of ACTH. CONCLUSION: Local side effects are minimal after the administration of Etomidat-Lipuro and Hypnomidate. Alfentanil reduces the injection pain of etomidate induction agents. Cortisol and aldosterone are depressed by etomidate, but the clinical relevance is minimal after a single bolus injection. Registry Numbers 0 (Emulsions). 0 (Propanediols). 2078-54-8 (Propofol). 33125-97-2 (Etomidate). ISSN 0003-2417 Publication Type Clinical Trial. Journal Article. Randomized Controlled Trial. Language German H. Monty Spangler, MD Clinical Instructor Dept of EM Bowman Gray School of Medicine