Intravenous Etomidate for Procedural Sedation in Emergency Department Patients

Abstract

Abstract. Objective: To determine the safety and effectiveness of intravenous (IV) etomidate for the sedation of patients undergoing painful procedures in the emergency department (ED). Methods: A twopart feasibility study for ED patients receiving IV etomidate for painful ED procedures was undertaken. In the initial phase, a retrospective series of patients receiving etomidate for ED procedural sedation was considered. This phase served as the basis for a descriptive, prospective feasibility study of consecutive ED patients. During the second phase, patients were evaluated for complications related to IV etomidate sedation or the procedure performed. Immediately following the procedure, the physician was asked to complete a data collection sheet documenting the patient's etomidate dose, the number of doses required to complete the procedure, the analgesic used, the complications of the procedure, and the patient's procedural recall. Results: Intravenous etomidate was administered to nine patients during the initial study phase and 51 during the prospective, descriptive phase. Indications for sedation included dislocation reduction (25), cardioversion (7), fracture reduction (20), abscess incision and drainage (4), foreign body removal (3), and chest thoracostomy (1). Physicians used 0.1-mg/kg IV bolus etomidate. A mean of 1.6 doses of etomidate was used to complete procedures (range 1-3 doses). Of the 60 patients in both study groups, 59 (98%) achieved adequate sedation by physician's assessment. Procedural success was documented for 56 patients (93%). There were 12 complications reported: oxygen desaturation below 90% (5), myoclonus (4), vomiting (1), pain with injection (1), and a brief bradycardic episode (1). No patient required assistance with ventilation or endotracheal intubation. Conclusions: Intravenous etomidate can be administered safely and effectively to provide appropriate conscious sedation for short, painful ED procedures. Key words: etomidate; sedation; conscious sedation; emergency department procedures. ACA-DEMIC EMERGENCY MEDICINE 2001; 8:13-18 E TOMIDATE is an imidazole hypnotic agent commonly used for emergent intravenous (IV) induction preceding endotracheal intubation. Its use in this setting continues to gain favor among emergency physicians (EPs), who value its rapid onset of action, short duration of sedation, and minimal respiratory and hemodynamic effects. A recent survey evaluating intubation practices at U.S. academic emergency departments (EDs) documented etomidate as the preferred induction agent in 23% of surveyed EDs. Patients who undergo painful procedures in the ED often require sedation and muscle relaxation for short periods. The strengths that are cited for the use of etomidate as an induction agent would infer value as a sedative agent. However, to the best of our knowledge, etomidate has received little attention within the context of procedural sedation. [2][3][4][5][6] In the setting of emergent procedural sedation, the shorter duration of action of etomidate relat...

Recall after procedural sedation in the emergency department

“…Our procedural success rate of 87% is consistent with previous reports. 9 The use of any propofol for the PS was associated with higher satisfaction scores for physicians, nurses and patients and no untoward effects the next day. However, the use of midazolam was associated with a decreased likelihood of delayed recall and a higher patient satisfaction.…”

Lidocaine pretreatment reduces the frequency and severity of myoclonus induced by etomidate

“…Therefore, etomidate is a frequently preferred agent for hemodynamically unstable patients [1]. However, etomidate formulated with propylene glycol is associated with side effects including injection pain and myoclonus [2,3].…”

Safety and Clinical Effectiveness of Midazolam versus Propofol for Procedural Sedation in the Emergency Department: A Systematic Review

“…1,3,4 Ketamine, etomidate, ketafol, and methohexital are used less commonly in adults, and ketamine and etomidate are associated with minor yet bothersome side effects (emergence and myoclonus, respectively), which may limit their widespread use in this patient population. 2,[5][6][7][8][9] Cohort studies, registry data, and small randomized controlled trials (RCTs) suggest that propofol and midazolam are safe and effective for use in PS. However, only few comparative studies have been conducted, and it remains unclear whether one agent is superior with regard to safety and clinical effectiveness endpoints.…”