In this episode, I’ll discuss alternatives to etomidate during the shortage.
Despite there being multiple manufacturers, some institutions are unable to resupply etomidate stock due to shortages at nearly all manufacturers.
The most common uses of etomidate are for sedation – either an anesthetic dose for rapid sequence intubation or a sub-anesthetic dose for deep sedation procedures like reduction of dislocated joints in the ED.
Common alternatives to etomidate for rapid sequence intubation are propofol or ketamine. Propofol is typically given at a dose of 2 mg/kg IV although a lower dose may be sufficient in elderly or debilitated patients. Ketamine is typically given at a dose of 1-2 mg/kg IV.
Common alternatives to etomidate for deep sedation for procedures are also propofol and ketamine. In this scenario however propofol is given in much lower doses to avoid respiratory depression as the goal is for the patient to maintain their own airway and breathing during the procedure. A dose of 0.5 to 1 mg/kg is given IV and this is followed every few minutes by 0.25 to 0.5 mg/kg until the procedure is complete. Alternative approaches that involve giving small aliquots of propofol such as 20 mg every 10 seconds until desired effect may also be used as this should also avoid respiratory depression in most patients. Ketamine is given for procedural sedation at the same dose as for rapid sequence intubation, 1-2 mg/kg IV and in the rare event the procedure extends past the ~10 minute duration of this initial dose, an additional 0.5 to 1 mg/kg may be given to extend the sedation.
The combination of midazolam and fentanyl was frequently used to provide deep sedation prior to the widespread acceptance of ketamine and etomidate which give the same depth of sedation with a much faster and reliable offset. Although no longer considered the ideal candidates for deep sedation, they might be considered an option for a unique patient if etomidate is not available and propofol and ketamine are not indicated. Dexmedetomidine may also be used in such a scenario although since clinicians are probably more familiar with other agents I would not expect this to be a realistic alternative to etomidate for procedural sedation.
One rare use for etomidate that has no alternative is in the emergency management of Cushings syndrome in a patient that cannot take oral medications. If you are concerned about being able to treat a patient like this with IV etomidate, you could consider reserving a supply in the event it was needed. Based on a case series that described using 2.5 mg/hr for an average of 8 days, 480 mg of etomidate would need to be reserved to treat one patient with this condition. Since this condition is rare, and it is even more rare for a patient to have it and not be able to tolerate surgery or oral medications, it may be reasonable to not reserve a supply of etmoidate for this during the shortage period. However I would suggest the decision to do so be mutual between pharmacy and endocrinology leaders at each institution.
Members of the Hospital Pharmacy Academy have access to training on Airway Pharmacology, where I cover the use of etomidate, propofol, and ketamine more in-depth as well as paralytic and sedative choices for the 6 different types of airway scenarios, and how to anticipate and deal with complications related to intubation. To get immediate access to this and other practical resources for hospital pharmacists, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Leave a Reply