etomidate (Rx)

>10%

Transient injection site pain (30-80%)

Skeletal muscle movements, mainly myoclonic (32%)

Opsoclonus (20%)

Adrenal suppression

1-10%

Hiccups

<1%

Apnea (duration: 5-90 seconds)

Arrhythmias

Hyperventilation

HTN

Hypotension

Hypoventilation

Laryngospasm

Nausea/vomiting

Oxygen desaturation

Snoring (may be associated with partial upper airway obstruction)

Contraindications

Hypersensitivity

Cautions

Adrenal suppression (and prolonged therapy)

Prolonged infusion associated with suppression of endogenous cortisol and aldosterone production; formulation is not intended for prolonged infusion

Exacerbations of underlying myocardial dysfunction reported; monitor

Risk of toxicity may increae in patients with renal impairment; used caution; monitor renal function

Elderly patients may require lower doses; use associated with cardiac depression, especially those with hypertension

Safety during labor and delivery not elucidated; not recommended

General anesthetics and sedation drugs in young children and pregnant women

• Brain development

  • Prolonged or repeated exposure may result in negative effects on fetal or young children’s brain development
  • Caution with use during surgeries or procedures in children younger than 3 yr or in pregnant women during their third trimester
  • Assess the risk:benefit ratio in these populations, especially for prolonged procedures (ie, >3 hr) or multiple procedures

Pregnancy

There are no adequate and well-controlled studies in pregnant women

There are insufficient data to support intravenous use in obstetrics, including Caesarean section deliveries; such use not recommended

Not known whether drug is excreted in human milk; because many drugs are excreted in human milk, use catuioin when administering to a nursing mother

Animal data

• In animal reproduction studies, fetal deaths and reduced pup survival were noted after intravenous administration of etomidate to pregnant rats at doses 0.17 times the human induction dose of 0.3 mg/kg
• Reduced pup survival was noted after intravenous administration of etomidate to pregnant rabbits at 1.6 times the human induction dose
• Published studies in pregnant primates demonstrate that the administration of anesthetic and sedation drugs that block NMDA receptors and/or potentiate GABA activity during the period of peak brain development increases neuronal apoptosis in developing brain of the offspring when used for longer than 3 hours
• There are no data on pregnancy exposures in primates corresponding to periods prior to third trimester in humans

Lactation

Not known whether drug is excreted in human milk; because many drugs are excreted in human milk, caution should be exercised when administered to a nursing mother.

Pregnancy Categories

A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

NA: Information not available.

Mechanism of Action

Nonbarbiturate hypnotic used for the induction of anesthesia; lacks analgesic activity; has minimal cardiovascular effects

Cushing syndrome (off-label): Blocks 11-beta-hydroxylase

Blocks steroidogenesis; 0.3 mg/kg will reduce plasma cortisol for up to 24 hr

Does not affect cardiac metabolism; no depression of cardiac output or of peripheral or pulmonary circulation

Absorption

Onset: Within 60 sec

Duration: 3-5 min due to redistribution from CNS

Distribution

Protein bound: 76%

Vd: 2-4.5 L/kg

Metabolism

Hepatic and plasma esterases

Elimination

Excretion: Urine, as inactive agent

IV Incompatibilities

Y-site: Ascorbic acid, vecuronium

IV Compatibilities

Syringe: Heparin

Y-site: Alfentanil, atracurium, atropine, ephedrine, fentanyl, lidocaine, lorazepam, midazolam, mivacurium, morphine sulfate, pancuronium, phenylephrine, succinylcholine, sufentanil

IV Administration

The IV infusion should be administered by healthcare professionals trained in the administration of general anesthetics and the management of complications encountered during its administration

Inject undiluted by direct IV injection over 30-60 sec; do not administer by prolonged IV infusion

Inject into large forearm vein

Consider lidocaine preadministration to minimize injection-site pain