Sedation after intubation using etomidate and a long-acting neuromuscular blocker.

BACKGROUND: Etomidate is an imidazole hypnotic which is commonly used by emergency medicine physicians during rapid sequence intubation. Etomidate's duration of action is significantly shorter than that of commonly used long-acting paralytic medications (3-12 minutes vs 25-73 minutes). If additional sedative medications are not administered in the paralyzed patient before the conclusion of etomidate's duration of action, patients are at risk for experiencing paralysis without adequate sedation.

OBJECTIVE: To evaluate the frequency of the administration of additional sedation in pediatric emergency department patients undergoing endotracheal intubation with etomidate and a long-acting paralytic agent.

METHODS: This study was a retrospective review of pediatric patients undergoing endotracheal intubation in a tertiary pediatric emergency department between July 2001 and December 2005. All patients intubated with etomidate and rocuronium or vecuronium were eligible for inclusion; patients with seizures were excluded. Data elements included the following: demographic variables, presenting complaint, intubation indication, medications used, time from etomidate administration to the administration of an additional sedative, Glasgow Coma Scale (GCS) score, and patient disposition.

RESULTS: During the study period, 276 pediatric intubations were reviewed with 104 patients receiving etomidate and rocuronium or vecuronium. Twenty cases were excluded, 15 cases with documented seizures and 5 incomplete/missing charts. Eighty-four records were included in the final analysis. The mean age is 84 +/- 65 months; 62 (73.8%) patients were male; the mean GCS was 8.44 +/- 3.9, with a median GCS of 8 (interquartile range 6,11), and 41 (48.8%) of patients presented with blunt trauma. The mean time from etomidate to the administration of additional sedation was 46 +/- 49 minutes. Eleven (13.1%) patients received no additional sedative after etomidate administration, whereas only 20 (23.8%) patients were given a sedative within 15 minutes of the administration of etomidate. Fifty-three (63.1%) patients received an additional sedative more than 15 minutes after the administration of etomidate.

CONCLUSIONS: A significant proportion of pediatric patients receiving etomidate and rocuronium or vecuronium during endotracheal intubation are likely experiencing ongoing paralysis without adequate sedation. Emergency medicine physicians should be cognizant of this when using these medications for facilitating intubation.