This document provides information about the drug etomidate. It discusses etomidate's history, mechanism of action, effects on body systems, pharmacokinetics, formulations, indications, contraindications, adverse effects, dosing, administration, safety, and relationship to adrenal suppression. The document also outlines cases for discussion and emphasizes that etomidate is the preferred induction agent for hemodynamically unstable patients.

2. How many of you are using etomidate in
your anesthesia practice ?
Yes / No
Will use of etomidate benefit in your
anesthesia practice ?
Yes / No
If you want to learn new drugs in
anesthesia then, will you use etomidate ?
Yes / No

3. Lecture Outline
• History
• Mechanism of Action
• Effects on different body systems
• Pharmacokinetics
• Formulation of Drug
• Indications
• Contra-indications
• Adverse effects
• Doses in different situations
• Administration of drug
• Safety Information
• Etomidate & Adrenal Suppression
• References
• Case Discussions
• Take Home message

4. History
• Etomidate discovered by Janssen ( J & J ) Pharmaceuticals in
1964 at Belgium (others drugs discovered are haloperidol, droperidol,
fentanyl, sufentanyl, alfentanyl & carfentanyl )
• First introduced as Anti-Fungal agent
• Introduced as IV Anesthetic agent ( due to potent sedative properties )
- In Europe 1972
- In USA 1983
- In India 2013
• Brand name in India -Troymidate, Lipuro & Etomid
• Brand name outside India-Hospira, Amidate & hypnomidate

5. Mechanism of Action
• Carboxylated Imidazole agent
• Imidazole agent in IV anesthetic drugs
• R-1-(1-ethylphenyl)imidazole-5-ethyl ester
• Acts directly on the Gamma Amino Butyric Acid
(GABA) receptor complex blocking neuroexcitation
producing sedation/hypnosis/anesthesia without
analgesia
• Acidic pH - 6.9, pKa – 4.2, poorly water soluble and
soluble in 35 % propylene glycol

6. Effects on different body system
* CNS – Decrease ICP, Cerebral Blood flow and
Cerebral Metabolism
But cerebral perfusion pressure maintained
* CVS -- No or Minimal changes in Heart Rate,
Blood Pressure and Cardiac Output
No hemodynamic changes in response to pain
No effect on Sympathetic tone
* RS – Minimal changes in Respiratory Rate and
Tidal Volume
Slight elevation in arterial carbon dioxide tension
(PaCO2)
Transient apnea up to 90 seconds

7. Other Effects
* No histamine release
* Very rare allergic reactions
* Hepatic and Renal blood flow decreased but
clinically accepted

8. Pharmacokinetics
Onset of Action : within 30 to 60 seconds
Peak Effect : In 1 minute
Duration : 3 to 5 minute and terminated
by redistribution
Protein Binding : 76 %
Metabolism : Hepatic & Plasma Esterase
Half-Life Distribution :3 Minutes ( Anesthesia )
Half-Life Redistribution : 30 Minutes ( Sedation )
Half-Life Elimination : 3 hours ( Drowsiness )

9. Formulation of Drugs
• Available as Milky White Solution in 35 % Propylene
Glycol
• Strength is 2mg/ml and 10 ml bulb is available in Indian
market
• Outside India 20 ml (40 mg) Preloaded Syringes also
available in 2mg/ml strength
• Now Etomidate is available with Medium and Long chain
triglycerides (MCT/LCT) for painless entry in vein.

11. Indications
• As Sedation ( PSA)
• As Conscious Sedation
• As Hypnotic Agent
• Etomidate Interview in Lie Detector Test
• As Anesthetic Agent ( preferred in cardiac patients)
• In Rapid Sequence Intubation (RSI)
• In Cardio version as Premedication
• In ICU as infusion ventilated/nonventilated patient
• As eSAM ( Etomidate Speech And Memory Test)
( To determine speech lateralization in patient prior to performing lobectomies to remove
epileptogenic centers in brain )

12. Contra-Indications
• Proven sepsis with unstable hemodynamic
patients
• Abnormally Low Blood Pressure even with Rx
• Decreased Function of the Adrenal Gland
• Hypersensitivity of Etomidate
• Pediatric Patients less than 10 years age ( but
people have started using etomidate up to 2 years
age with risk-benefit profile)
• In Pregnancy try to avoid as induction agent if
other anesthetic agents are available
• In Geriatric Patients with caution

13. Adverse effects
• Transient Injection site pain up to 80 % patients
• Skeletal Muscle movements mainly myoclonic
( peripheral limb movements ) up to 30 % patients
• Opsoclonus ( uncontrolled eye movements )
• Adrenal Suppression up to 10 % patients
• Hiccups
• Apnea up to 90 seconds
• Less frequently laryngospasm, nausea/vomiting,
snoring, arrhythmia & increase in PaCO2

14. Doses in different situations
• For Sedation : 0.1 mg/kg up to three doses
• For G/A 0.3 to 0.4 mg/kg IV over 30-60 seconds
• In ICU : As continuous infusion 0.04 to 0.05
mg/kg/hr with continuous monitoring
• In Cushing Syndrome or law cortisol level pat.
0.2 mg/kg
• In Geriatric patients : 0.2 mg/kg
• In Pregnancy : 0.2 mg/kg
• In Pediatric Patients : 0.1 to 0.3 mg/kg

15. Administration of Drug
• Never dilute Etomidate with DW in same
Syringe
• Preferably Large Vein for IV administration
• Preadministration of lidocaine if possible (2 ml)
• First dose to be completed within one arm-
brain circulation (30 seconds )
• All muscle relaxants, benzodiazepines,
narcotics and ketamine are compatible with
etomidate in same syringe except vecuronium
and vit-c.

16. Safety Information
* Etomidate causes drowsiness from 3 to 9 hours so
Patients are instructed
-Do note drive
-Do not operative machinery
-Do not drink alcohol for 24 hours
• Use with cautions in Geriatric and Pregnant pts.
• Less than 10 years children manufacturer has not
recommended

17. Etomidate & Adrenal Suppression
* Single dose etomidate causes measurable
decrease in level of circulating cortisol
• But it never falls below physiological range
• Effect of low level remains up to 24 hours
• 100 to 200 mg hydrocortisone is preferable
before etomidate administration
• In Sepsis and Septic Shocks there is already
low level of cortisol so etomidate is not
advisable for induction
• After three repeated doses etomidate shold
be avoided

18. Best Anesthetic Agent for PSA
PSA ( Procedural Sedation and Analgesia)
• The American College of Emergency Physicians
(ACEP) defines procedural sedation as "a
technique of administering sedatives or
dissociative agents with or without analgesics to
induce a state that allows the patient to tolerate
unpleasant procedures while maintaining
cardiorespiratory function. Procedural sedation
and analgesia (PSA) is intended to result in a
depressed level of consciousness that allows the
patient to maintain oxygenation and airway
control independently

20. Etomidate is most preferred drug
in
Hemodynamically unstable
patients
then any other anesthetic agents
for induction of anesthesia

21. What journals say about Etomidate

31. Etomidate + Ketamine Mixture
• Most suitable mixture for short procedure
• Best combination for RSI in trauma and sepsis
patients
• Good alternative in pedo patients compare to
ketofol
• Both counter act each other adverse effects like
myoclonus, nystagmus, injection site pain
• Dose is 0.1mg/kg etomidate + 1 mg/kg ketamine
• I have use almost in 50 short cases e.g.
colonoscopy, upper GI scopy and circumcision

33. Case Discussion

34. 1) Colonoscopy in triple vessel disease
2) Ludwig’s Angina in old age patient

35. Take Home Message
• The drug of choice in all types of cardiomyopathies
• When etomidate is used as sole anesthetic agent for
induction or in any short procedure fentanyl group
drugs or ketamin are must as premedication
because of very short duration effect of etomidate
• In Pregnancy with Heart Disease etomidate is drug of
choice
• In traumatic brain injury and severe trauma patients
with unstable hemodynamic patient etomidate is
preferred
• Universally accepted anesthetic agent in PSA and RSI