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The safety of etomidate for emergency rapid sequence intubation of pediatric patients
P E Sokolove1, D D Price, P Okada
1Division of Emergency Medicine, University of California Davis School of Medicine, Davis and UC Davis Medical Center, Sacramento, 95817, USA. pesokolove@ucdavis.edu
Insights
Etomidate use in pediatric rapid sequence intubation (RSI) showed low rates of significant hypotension and no adrenal insufficiency. Further studies are needed to compare its safety with other induction agents in children.
Area of Science:
- Pediatric Emergency Medicine
- Pharmacology
- Critical Care
Background:
- Etomidate is an induction agent used for rapid sequence intubation (RSI).
- Concerns exist regarding its potential to cause hypotension and adrenal insufficiency in pediatric patients.
Purpose of the Study:
- To evaluate the incidence of clinically important hypotension and adrenal insufficiency in pediatric patients receiving etomidate for RSI in the emergency department (ED).
Main Methods:
- Retrospective review of 100 pediatric patients (<10 years) undergoing RSI with etomidate.
- Data collected included blood pressure changes and corticosteroid use during hospitalization.
- Clinically important hypotension defined as SBP < 1 SD below normal for age.
Main Results:
- No clinically significant adrenal insufficiency was observed (0/99 patients received corticosteroids for this indication).
- A low incidence of clinically important hypotension was noted (4.8% of patients).
- Mean blood pressure change was minimal, with no statistically significant decrease.
Conclusions:
- Etomidate appears to be associated with a low incidence of clinically important hypotension and no significant adrenal insufficiency in pediatric RSI.
- Further prospective studies are warranted to compare etomidate's safety profile with alternative induction agents in this population.
Objective:
To determine whether pediatric patients given etomidate for rapid sequence intubation (RSI) in the ED develop clinically important hypotension or adrenal insufficiency.
Methods:
Retrospective review of 100 consecutive patients younger than age 10 years given etomidate for RSI in the ED at two academic medical centers. Data were abstracted from ED and in-patient medical records. Clinically important hypotension was defined as a decrease in systolic blood pressure (BP) measurement to below one standard deviation (SD) of mean normal for age. Clinically important adrenal insufficiency was defined as the need for exogenous corticosteroid replacement for suspected adrenal insufficiency at any time during hospitalization.
Results:
BP measurements before and within 20 minutes after etomidate administration for RSI were recorded on 84 intubations (84%). The mean change in BP between pre-intubation and post-intubation measurements was a decrease of 1 mmHg (95% CI: -6 mm Hg to +7 mm Hg, P = 0.83). When expressed as a percentage of normal BP for age, the mean change in BP was a decrease of 1% (95% CI: -7% to +6%, P = 0.82). Four patients (4.8%; 95% CI: 1.3-11.7%) had a systolic BP decrease to below one SD of mean normal for age. Fourteen patients received corticosteroids during hospitalization, but none (0/99, 95% CI: 0-3.7%) for suspected adrenal insufficiency.
Conclusions:
We found no evidence of clinically important adrenocorticoid suppression and a low incidence of clinically important hypotension when using etomidate for emergent pediatric RSI. Because other induction agents may also result in hypotension, prospective comparison studies are needed to further evaluate the safety of etomidate in this patient population.