Clinical beta

FMBM is currently in clinical beta. Content is for professional review/testing and must not replace local protocols, senior clinical judgment, or official prescribing references.

Drug Monograph

Etomidate

USE IF: RSI in unstable/shock patients, short procedures requiring stable BP

AVOID IF: Septic shock (relative), adrenal insufficiency, prolonged sedation

Etomidate

IV anesthetic (GABA-A modulator, imidazole derivative)

RSIInductionHemodynamically stableAdrenal suppression

Indication

RSI in unstable/shock patients, short procedures requiring stable BP

At a glance

INDICATION -> Hemodynamically stable induction agent with NO analgesia and adrenal suppression risk

ADULT DOSE -> RSI: 0.2-0.3 mg/kg IV

MAX DOSE -> Practical: 0.3 mg/kg (avoid >0.4-0.6 mg/kg)

CONTRA -> Continuous infusion, repeated dosing, relative caution in septic shock/adrenal insufficiency

ANTIDOTE -> None (supportive +/- steroids if adrenal crisis)

Quick facts

Onset

30-60 sec

Duration

Peak ~1 min; duration 3-5 min; half-life ~75 min (prolonged in critical illness).

Routes

IV only

Pregnancy

Use if benefit outweighs risk

Renal

No adjustment for single dose

Hepatic

Reduce dose

Do not miss

Time to action: onset 30-60 sec

Adrenal risk

  • Adrenal suppression after single dose can persist for 24-72 hours.

Critical risks

  • NO analgesia -> add opioid/analgesia after intubation.
  • Avoid infusion due to mortality/adrenal suppression concerns.
  • Myoclonus is common and may mimic seizure activity.

Antidote

  • No specific antidote; supportive care (consider steroids if adrenal crisis suspected).

High-risk scenarios

  • Always plan post-intubation sedation BEFORE giving etomidate.

Key interactions

  • Opioids.
  • Benzodiazepines.
  • Propofol.
  • Chronic steroid therapy.

Indications

Primary

  • RSI induction in hemodynamic instability
  • General anesthesia induction

Secondary

  • Short procedures (e.g., cardioversion, reductions)

Other

  • Cushing syndrome suppression (specialist use)

Dosing

Standard: RSI: 0.2-0.3 mg/kg IV

Max daily dose

  • Typical RSI target 0.2-0.3 mg/kg IV; avoid high/repeated boluses.

Adult - IV

  • Standard induction: 0.3 mg/kg IV.
  • Elderly/shock: 0.15-0.2 mg/kg IV.

Adult - IV

  • Avoid repeated boluses when possible.
  • Do NOT use continuous infusion for ICU sedation.

Pediatric

  • 0.2-0.3 mg/kg IV (specialist use).

Renal adjustment

  • No dose change usually needed for single dose.

Hepatic adjustment

  • Reduce dose with cautious titration.

Warnings

Clinical warnings

  • Adrenal suppression via 11beta-hydroxylase inhibition.
  • Respiratory depression/apnea.
  • Myoclonus.
  • Hypotension can still occur (less than propofol).
  • No analgesia increases post-induction awareness/pain risk without follow-up sedation/analgesia.

Adverse effects

  • Common: myoclonus, nausea/vomiting.
  • Serious: apnea, hypotension, adrenal insufficiency.

Contraindications / caution

Do not use

  • Known hypersensitivity.

Use caution / avoid high doses

  • Adrenal insufficiency.
  • Sepsis: use is controversial; avoid repeated dosing/infusion due to adrenal suppression risk.
  • Chronic steroid use.
  • Elderly.
  • Liver disease.

Drug interactions

  • Opioids -> increased respiratory depression.
  • Benzodiazepines -> additive CNS depression.
  • Propofol -> additive hypotension/sedation.
  • Chronic steroid therapy -> greater adrenal crisis concern.

Special populations

Pediatrics

Weight-based specialist dosing.

Pregnancy

Use when needed; may be preferred over more hypotensive agents in shock.

Breastfeeding

Generally safe after maternal recovery.

Elderly

Reduce dose.

Liver disease

Effect may be prolonged; reduce dose.

Renal impairment

No routine adjustment for single-dose use.

Administration

  • IV bolus over 30-60 sec.
  • In RSI, give paralytic immediately after etomidate.
  • Prepare post-intubation sedation/analgesia beforehand.
  • Avoid repeated boluses.
  • NEVER use continuous infusion (risk of prolonged adrenal suppression).

Monitoring

  • Continuous ECG, BP, SpO2.
  • Airway and ventilation status.
  • Post-induction hemodynamics.
  • In high-risk patients, monitor for adrenal insufficiency for 24-48 h.

Overdose / toxicity

Airway + ventilation -> hemodynamic support -> consider adrenal crisis (hydrocortisone if needed).

Recognition

  • Toxicity is variable and more likely with high/repeated dosing.
  • CNS depression, apnea, and hypotension can occur.

Immediate actions

  • Ventilatory support.
  • Fluids and vasopressors as required.
  • Consider hydrocortisone if adrenal crisis is suspected.

Antidote

  • No specific antidote.

Decontamination

  • Not relevant for parenteral overdose.

Escalation

  • ICU for ongoing cardiorespiratory or endocrine instability.

Clinical pearls

Common mistakes, resistance logic, and bedside traps

Shock RSI fit

  • Often the best induction choice in hypotension/cardiogenic shock.

Sepsis caveat

  • Not ideal in septic shock because adrenal suppression may worsen outcomes.

Post-tube plan

  • Always follow immediately with sedation and analgesia after intubation.

Hypnosis and cortisol

  • Provides hypnosis ONLY - NO analgesia (must add opioid if needed).
  • Single dose can suppress cortisol synthesis for about 24 hours; clinical significance in sepsis is debated.

Myoclonus interpretation

  • Myoclonus does not necessarily indicate seizure.

Infusion rule

  • Never use etomidate as continuous ICU sedation infusion.

Pharmacokinetics

  • Rapid CNS penetration.
  • Hepatic plus plasma ester metabolism.
  • Renal excretion of inactive metabolites.
  • Half-life can be prolonged in critical illness.

Mechanism of action

  • Potentiates GABA-A receptor activity causing CNS depression.
  • Inhibits 11beta-hydroxylase and reduces cortisol synthesis.

Common brand names

Saudi Arabia

Amidate · Etomidate-Lipuro

Global

Hypnomidate · Generic etomidate

Common trade names are curated examples only — formulations and availability vary. Verify the exact product name with your local pharmacy and national regulator before prescribing or dispensing.

Country practice notes

  • Common RSI agent in GCC ER/ICU for trauma and cardiogenic shock.
  • Available as Amidate and Etomidate-Lipuro in hospital formularies.
  • Often chosen when propofol is avoided because of hypotension risk.
  • Use in sepsis remains controversial in regional practice.

Saudi Arabia — confirm with local formulary.