Lesson 6 of 16
Rapid Sequence Intubation (RSI): Etomidate For RSI
Mechanism of action
Etomidate is GABA receptor agonist that blocks neuroexcitation and induces unconsciousness.
Etomidate is imidazole-derived which is sedative-hypnotic that is a commonly used induction agent for RSI.
- The most common dose used is 0.3 mg/kg IV
- An adjusted body weight is recommended in morbidly obese patients.
- 15-45 seconds
- 3-12 minutes
- Myoclonus can occur 25-63%
- Can be mistaken for seizure activity
- Pain on injection
- Thought to be due to diluent propylene glycol
- Adrenal Suppression
- Inhibits corticoneogenesis and 11β-hydroxylation which may decrease cortisol and aldosterone levels, resulting in prolonged suppression.
- Etomidate causes reduction in intraocular pressure (IOP).
Impact on Hemodynamics
|Blood Pressure (BP)||Heart Rate (HR)||Cardiac Output (CO)||Intracranial Pressure (ICP)|
|↔ No Impact||↔ No Impact||↔ No Impact||↓ Decrease|
- Etomidate has no analgesic effects.
Gold standard induction agent for RSI
|Author, year||Design/ sample size||Intervention & Comparison||Outcome|
|Lyons, 2015||Cohort study/ n=261||Etomidate+ Succinylcholine (Group 1) |
Fentanyl+ ketamine+ rocuronium (Group 2)
|Significantly better laryngeal views with fentanyl/ketamine/rocuronium group |
100% first attempt intubation with fentanyl/ketamine/rocuronium group
↑ post-intubation MAP+ HR with etomidate + succinylcholine
|Bruder, 2015||Cochrane Review||Etomidate|
|There was no difference in mortality, hospital LOS, duration of ventilation, and duration of vasopressors|
Etomidate associated with ↑ ACTH and ↓ in cortisol level
|Tekwani K, 2010||RCT/ n=122||Etomidate 0.3 mg/kg |
Midazolam 0.1 mg/kg
|No significant differences in median hospital LOS (9.5 vs 7.3 days), ICU LOS (4.2 vs 3.1 days), In-hospital mortality ( 26% vs 43%), or ventilator days|
|RCT/ n=469||Etomidate 0.3 mg/kg|
Ketamine 2 mg/kg
|No difference in intubating condition, SOFA score, 28-day mortality, Ventilator free days, vasopressor support, or GCS|