We often have many medications at our disposal when it comes to sedation for our patients. Of all the options that we have, one of the most interesting ones is etomidate, which I'm going to discuss in this lesson here. Alright you guys, welcome back to another video lesson from ICU Advantage. My name is Eddie Watson, and my goal is to give you guys the confidence to succeed in the ICU by making these complex critical care subjects easy to understand.
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Again, those are found at the website, icuadvantage.com forward slash support, link down in the description. All right, of the sedatives... propofol is one of the most common ones that we use for a multitude of different purposes.
I will link to a lesson up above that I already did looking at this specific medication. Propofol, as well as Versed, do have some negative effects that can be potentially detrimental in some critically ill patients. Knowing this though, we do have another option that is actually quite interesting and a useful option, and that is Atomidate.
So let's actually start off and talk about what exactly Atomidate is and then how it is that it works. So Atomidate, which also goes by the trade name Amidate, is a short-acting, non-barbiturate, intravenous anesthetic agent. I know that was a mouthful, but it was discovered first in 1964, and it found its first uses in Europe and then the US in the 70s and early 80s.
Now, the interesting thing about Atomidate is it's actually structurally unrelated to our other anesthetic agents, and it works by binding with our GABA receptors. and really increasing the affinity of GABA for those receptors. So its action is actually referred to as a positive modulator of GABA, which GABA is the primary inhibitory neurotransmitter in our brain.
The end result of this is the reduction of the neuronal excitability, which is what produces the anesthetic properties. Now important to know is while it has anesthetic and amnesic properties like other anesthetic and sedative medications, it does not have analgesic properties. So our patients are not going to get pain relief from this medication.
And the goal with its use is really to rapidly produce unconsciousness in our patients. Like I mentioned though with propofol and ver said that those do have some potentially negative effects. And so I do want to talk about some of the positive effects that Atomidate has, especially when comparing it to some of our other agents.
And the first of these I want to talk about are going to be our cardiovascular effects. And so really one of the big benefits of etomidate is its minimal hemodynamic profile. And so what this means is that there's minimal effect on vasodilation, as well as this medication does not lead to the release of histamine.
We do see some relaxing of the vasculature, so we can see some mild drops in arterial blood pressure, but certainly significantly less than what we'd see with Versed or especially propofol. We also usually don't see any impact to contractility or cardiac output. And so because of these, Atomidate may be a good choice to use in patients who are hemodynamically unstable.
Now when we look at some of our respiratory effects, Atomidate actually has minimal effects on ventilation, and it's typically not going to result in apnea for a patient. That said, if we do administer this concurrently with other CNS depressants, such as opioids, then we may actually see this occur. And then finally for our CNS effects, one interesting thing is that with etomidate, we do see reduction in cerebral metabolic rate, and unlike propofol, we see cerebral vasoconstriction leading to decreased cerebral blood flow.
Together, these lead to decreases in intracranial pressure. So a pretty interesting profile of effects that we have with this medication when we compare it to some of the other ones that we typically use. Now, there are a couple adverse effects to be aware of. The first and probably the most major one that gets a lot of attention is actually going to be adrenal suppression.
And with this medication, we do see a transient inhibition of adrenal steroid synthesis. And this lasts anywhere from 6 to 12 hours, usually about 8 hours, following a bolus dose. And this inhibition is also dose dependent. There were some questions over time about using this medication in patients with sepsis, but evidence is really unclear if there's any impact to mortality in doing this, but it may. also be contraindicated in patients with adrenal insufficiency.
Now probably the most common adverse effect of this medication is something pretty simple and it's simply injection site pain. And so because etomidate must be prepared in a propylene glycol mixture, it can often cause pain at the injection site, especially when we're injecting it into smaller peripheral veins. Now we can reduce this by either infusing it into larger veins as well as with the use of lidocaine. Another adverse effect of this medication is myoclonus, similar to something that we potentially see with propofol. And here, this is skeletal muscle twitching that can be observed after the administration of this medication.
If we do pre-medicate with some other CNS depressants, such as opioids, we can actually see a reduction in this, as well as a concurrent administration with a paralytic, which we often will do in cases of intubation, that this is obviously going to mask this. Another adverse effect that also is potentially a benefit in some of its uses that I'm not really going to discuss here, but... we do see a lowering in the threshold for seizures. And then finally, the last adverse effect here is nausea and vomiting.
And so unlike propofol, which actually has anti-emetic properties, etomidate doesn't actually have this. So as a result, nausea and vomiting can occur after the patient awakens. All right, so now let's talk a little bit about our dosing.
So our typical dose for etomidate is going to be 0.2 to 0.6 milligrams per kilogram IV push. And we're going to give this over about 30 to 60 seconds. Now it does actually have a very rapid onset.
So and that onset is over about 30 to 60 seconds as well. Now one of the interesting things with this is the duration is actually dose dependent. So for every 0.1 milligram per kilogram, we see about 100 seconds of unconsciousness.
So if we gave a 0.3 milligram per kilogram dose, we'd see about 300 seconds of unconsciousness or about five minutes. Now we don't use any continuous infusions of this medication specifically because of the sustained adrenal suppression. So we're only going to give this medication as bolus push doses.
And then we're typically going to find etomidate prepared in a 2 mg per ml concentration. And so typically we're going to see these in prepared vials of either 20 mg in 10 ml or 40 mg in 20 ml. And then... Atomidate is actually metabolized by the liver as well as an enzyme in the blood and it is excreted via the kidneys. All right, and then finally, let's just talk about our uses of this medication in critical care, really the common ways that you guys are going to see this medication.
And so while Atomidate can be used actually as an induction for anesthesia, the primary ways that we're going to use it in the ICU is really as an induction agent for intubation and RSI, as well as potentially for procedural sedation. Now our common dosing when we're doing this is 0.2 to 0.3 milligrams per kilogram, again IV push. So a quick example here is if you have a 100 kilogram patient that they would get 20 to 30 milligram dose.
Typically seems like a pretty quick calculation for most patients that fall in kind of our normal weight ranges is usually to give the patient around 20 milligram dose and then that either puts us on the high end of this range or the low end depending if their weight is a little bit higher. Obviously, you can do a pretty quick calculation of this on the fly and determine the exact dose that you need to give, but this is just kind of commonly what I've seen with it. Now when it comes to intubation, we are often going to combine this with an analgesic as well as a paralytic for the induction. Again, make sure that we're giving our analgesic and our sedative medication before we give our paralytic.
And then for procedural sedation, we're not usually going to use a paralytic, and then we may or may not use it with an analgesic at that time. Otherwise, pretty straightforward use. We're going to give this medication prior to either the intubation or prior to the procedure that we're doing.
And that was our review of Atomidate. I really hope that you guys found this lesson enjoyable and useful. A lot of good information in here, and Atomidate is actually a quite interesting medication, and it seems to have a lot of good uses in critical care, especially when we're dealing with those hemodynamically unstable patients, which is something that we definitely do come across. So I hope that you guys found this information useful. If you did, please leave me a like on the video down below.
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