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Abstract & Commentary
Source: Guldner G, et al. Etomidate for rapid-sequence intubation in young children: Hemodynamic effects and adverse events. Acad Emerg Med 2003;10:134-139.
Etomidate, an imidazole derivative commonly used for rapid sequence intubation (RSI) in the emergency department (ED), is indicated for this purpose in patients 10 years and older. Despite this fact, it frequently is used for both procedural sedation and RSI in more diverse pediatric patient populations. The objective of this study was to enumerate and quantify any adverse effects associated with its use for RSI in a pediatric patient population. Conducted at Loma Linda University Hospital, this retrospective, implicit chart review examined the records of all patients ages 0 to 10 years who underwent RSI using etomidate as the induction agent during a period of approximately five years. The stated goals of the study were three-fold: 1) to evaluate the frequency of the immediate adverse events of vomiting, seizures, and myoclonus; 2) to look for adverse hemodynamic effects; and 3) to assess for the delayed adverse effects of adrenocorticoid suppression or recurrent seizures.
All data abstractors underwent training on practice medical records, and results were recorded on standardized data collection forms. Study variables were explicitly defined, and 15% of charts underwent duplicate review to confirm inter-rater reliability. A kappa of at least 0.6 was the standard (indicating good inter-rater reliability).
The authors identified 105 children who had undergone RSI. Average age was 3 years (± 2.9). The median dose was 0.32 mg/kg (± 0.12) of etomidate. Fifty-seven percent of intubations were for trauma, 20% for non-traumatic respiratory distress, and 13% were non-traumatic altered mental status. Of the 105 intubations, four had immediate adverse events documented (3.8% of patients, 95% CI 1.0-8.8%). There was one case of transient desaturation during RSI (single successful attempt), and three cases of emesis after induction with etomidate (one prior to intubation and two after).
Approximately half of the study patients (52 of 105) had adequate documentation of blood pressure and pulse prior to RSI and within 10 minutes after. From these cases the results showed an average increase in systolic blood pressure of 4 mmHg (95% CI -3.3 mmHg to 11 mmHg) and an average increase in diastolic blood pressure of 7 mmHg (95% CI -3.1 mmHg to 11 mmHg). The mean change in pulse was an increase of 10 bpm (95% CI 4.0-17.4 bpm). In the authors’ search for delayed sequelae, they found no cases of adrenal insufficiency nor did they identify any new-onset seizures.
Commentary by Andrew D. Perron, MD
The use of etomidate as an induction agent in RSI has become widespread in emergency medicine. Its use is advocated due to its rapidity of onset, brevity of action, and minimal effects on cardiovascular stability. A number of studies in adult emergency patient populations have demonstrated this to be true. In clinical practice, etomidate frequently is used on pediatric patient populations for RSI, as these benefits also are assumed to apply to this group. Supportive literature is relatively sparse, however. In a previous retrospective review on this subject, Sokolove et al found a similar lack of effect on blood pressure or adrenal function in 100 pediatric patients induced with etomidate.1 Other studies of etomidate used in adult populations have reported frequent episodes of myoclonus, with a reported incidence of up to 70%.2 This series found no episodes of myoclonus, a fact the authors rightly suspect is related to the concomitant administration of a paralytic with the etomidate. Anesthesia literature has suggested a connection between the use of etomidate and seizures. However, studies in adult ED populations almost universally have not found this complication to occur, and this study follows this trend. Finally, the incidence of vomiting approximates that seen in other studies, and is similar to the incidence associated with other induction agents.
Etomidate rapidly is becoming the de facto drug of choice for RSI in the ED in a wide variety of clinical situations. While a relatively large number of good adult studies have shown this, the literature in the pediatric population is sparse. Although the manufacturer has yet to recommend etomidate for RSI in patients younger than 10 years of age, the available literature suggests that it has a very favorable risk-benefit profile, and can be used safely in this group.
Dr. Perron, Department of Emergency Medicine, Maine Medical Center, Portland, ME, is on the Editorial Board of Emergency Medicine Alert.
1. Sokolove P, et al. The safety of etomidate for emergency rapid sequence intubation of pediatric patients. Pediatr Emerg Care 2000;16:18-21.
2. Johnson D, et al. The safety and efficacy of etomidate as an adjunct to endotracheal intubation in the emergency department (abstract). Acad Emerg Med 1994;1: 318-319.