Etomidate as a Sedative in Critical Care

Introduction

• Instructor: Eddie Watson
• Channel: ICU Advantage
• Objective: Understand Atomidate as a sedative in the ICU
• Resources: Notes available to YouTube and Patreon members
• Website: icuadvantage.com

Common Sedatives

• Propofol: Frequently used, but can have negative effects in critically ill patients
• Versed: Also used but has potential detriments
• Etomidate: An alternative sedative with distinct properties and uses

What is Etomidate?

• Trade Name: Amidate
• Type: Short-acting, non-barbiturate, IV anesthetic
• Discovery: 1964, first used in Europe, then US in 70s and 80s
• Mechanism of Action:
  • Binds to GABA receptors
  • Increases affinity of GABA
  • Positive GABA modulator
  • Reduces neuronal excitability (anesthetic properties)
• Properties: Anesthetic and amnesic, not analgesic

Benefits vs Other Sedatives

Cardiovascular Effects

• Minimal Hemodynamic Impact: Low effect on vasodilation and histamine release
• Blood Pressure: Mild drops in arterial blood pressure, less significant than Propofol or Versed
• Hemodynamically Unstable Patients: Good choice due to minimal impact on contractility and cardiac output

Respiratory Effects

• Minimal Impact: Typically does not cause apnea
• Concurrent Drugs: May cause apnea if used with CNS depressants like opioids

CNS Effects

• Cerebral Metabolic Rate: Reduction
• Cerebral Vasoconstriction: Decreases cerebral blood flow and intracranial pressure

Adverse Effects

Adrenal Suppression

• Duration: 6-12 hours, typically ~8 hours after bolus dose
• Mechanism: Transient inhibition of adrenal steroid synthesis
• Consideration: Possibly contraindicated in adrenal insufficiency

Injection Site Pain

• Cause: Prepared in propylene glycol
• Mitigation: Infuse in larger veins or use lidocaine

Myoclonus

• Description: Skeletal muscle twitching
• Reduction: Premedication with CNS depressants or concurrent administration of a paralytic

Lower Seizure Threshold

Nausea and Vomiting

• Cause: Unlike Propofol, Etomidate does not have anti-emetic properties

Dosing

• Typical Dose: 0.2 - 0.6 mg/kg IV push over 30-60 seconds
• Onset: 30-60 seconds
• Duration: Dose-dependent (0.1 mg/kg = 100 seconds)
• Administration: Bolus push doses only, no continuous infusion
• Preparation: 2 mg/ml concentration (20 mg in 10 ml or 40 mg in 20 ml)
• Metabolism: Liver and enzyme in blood, excreted via kidneys

Uses in Critical Care

Induction for Intubation and RSI

• Dosing: 0.2-0.3 mg/kg IV push
• Procedure: Combine with analgesic and paralytic; administer analgesic and sedative before paralytic

Procedural Sedation

• Analgesic: May or may not be used
• Paralytic: Not typically used

Conclusion

• Utility: Particularly beneficial for hemodynamically unstable patients
• Feedback: Encouraged to like, comment, and subscribe to the channel
• Support: Available via YouTube or Patreon memberships, ICU Advantage website, and ICU Advantage stickers