ETOMIDATE
FOR PROCEDURAL SEDATION IN EMERGENCY MEDICINE.
STUDY OBJECTIVE: We describe and analyze the
effectiveness and safety of etomidate for procedural
sedation and evaluate the patient's perspective on effectiveness, side effects,
and satisfaction.
METHODS: We conducted an observational retrospective
study of all patients who received etomidate for
procedural sedation over 2 years in 3 affiliated suburban emergency departments
of a large group-model health maintenance organization. Data were abstracted
from the ED records. Additionally, a patient questionnaire was prospectively
administered by telephone.
RESULTS: Etomidate was used for
sedation in 134 patients between 6 and 93 years of age during 150 procedures.
The mean cumulative dose was 0.20 mg/kg. Adjunctive medication was used in 36
(23%) procedures. Moderate sedation with verbal arousability
was induced in 48 (32%) patients, and deep sedation with verbal
unresponsiveness was induced in 102 (68%) patients. Full recovery to the preprocedural level of alertness was achieved within 30
minutes in 142 (95%) of procedures. Mean changes in systolic blood pressure,
pulse rate, and oxygen saturation were clinically insignificant. There were 7
(4.7%; 95% confidence interval [CI] 1.9% to 9.4%) adverse events, including 5
(3.3%; 95% CI 1.1% to 7.6%) cases of oxygen desaturation
below 94% in older patients (>55 years of age) who received slightly higher
mean doses of etomidate (0.23 mg/kg). Four of these
patients received brief assisted bag-valve-mask ventilation and recovered
uneventfully; none required endotracheal intubation. The questionnaire was completed by 120 (90%) of
134 patients and involved 136 procedures. During 127 (93%) of these, etomidate was believed to be extremely effective in causing
sleep, and for 127 (93%) it induced complete procedural amnesia. Only 5 (4%)
patients experienced nausea or vomiting. Regarding willingness to receive etomidate for their next procedure, the patients' responses
were favorable: extremely, 95%; moderately, 2%; slightly, 3%; and not at all,
1%.
CONCLUSION: Etomidate is a
useful agent for carefully conducted procedural sedation because it provides
effective, brief, deep sedation with little hemodynamic
compromise. Its safety may be jeopardized by the occurrence of respiratory
depression in older patients receiving higher doses. Patients report a high
degree of satisfaction with etomidate.
ETOMIDATE AND
MIDAZOLAM FOR REDUCTION OF ANTERIOR SHOULDER DISLOCATION: A RANDOMIZED,
CONTROLLED TRIAL
Burton JH, et al. Ann Emerg
Med.2002;40:496-504.
STUDY OBJECTIVE: We determine whether patients with
acute, anterior shoulder dislocation undergoing emergency department procedural
sedation and analgesia (PSA) with intravenous etomidate
would experience a reduced time of impaired consciousness when compared with a
group of patients receiving intravenous midazolam.
METHODS: This study was a prospective, double-blinded,
randomized, institutional review board-approved trial of ED patients with
anterior shoulder dislocation. Patients were randomized to receive intravenous
boluses of etomidate (0.1 mg/kg) or midazolam (0.033 mg/kg) during PSA. The primary outcome for
comparison was PSA duration.
RESULTS: Forty-six patients with anterior shoulder
dislocation were enrolled: 22 in the etomidate group
and 24 in the midazolam group. Three patients
sustained reduction without physician or sedative intervention. Two patients
were excluded from protocol because of unavailable study drug or fracture
dislocation. The median lowest modified postanesthetic
recovery score observed during PSA was 5 (95% confidence interval [CI] 4 to 7)
in the etomidate group and 6 (95% CI 6 to 7) in the midazolam group. The median time of PSA for patients
receiving etomidate was 10 minutes (95% CI 8 to 15)
compared with 23 minutes (95% CI 16 to 30) for patients receiving midazolam, with a difference between the group medians of
13 minutes (95% CI 5 to 22). Reduction success was achieved in 37 (90%) of 41
patients: 2 did not experience reduction with etomidate
and 2 did not experience reduction with midazolam.
There were 15 PSA complications reported.
CONCLUSION: Etomidate provides
effective PSA for reduction of ED patients with anterior shoulder dislocation.
When compared with midazolam, etomidate
use confers a significantly shorter period of PSA.