For ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS), when surgery is not feasible, or in cases of severe biochemical disturbances, immunosuppression or mental instability, medical therapy with agents such as etomidate is indicated. We present our experience in using etomidate for a 41-year old female with EAS secondary to a malignant mediastinal paraganglioma. We were able to demonstrate that etomidate can be used effectively to control severe hypercortisolism in a lower dose than previously described.
Etomidate ; ACTH Syndrome, Ectopic

BACKGROUND: Etomidate frequently causes myoclonus. Since the myoclonus is caused by a transient disequilibrium due to etomidate exposure in the CNS, we hypothesized that a slow rate of injection of the drug may decrease the incidence of myoclonus. We conducted a prospective randomized study to compare the effect of two different types of the etomidate injection rate on the incidence and severity of myoclonus. METHODS: Fifty patients were randomly assigned to the fast-injection group (group F) or slow-injection group (group S): Group F patients received etomidate (0.3 mg/kg) over ten seconds. The same dose was administered over two minutes for group S patients. The response to the injection of etomidate was graded on a four-point scale in a blinded manner. The time to loss of consciousness (LOC) was also recorded. RESULTS: The incidence of myoclonus was significantly lower (P < 0.001) in group S patients; 84% and 28% in group F and group S patients, respectively. The myoclonus was also significantly less severe in group S patients (P < 0.001). The time to LOC was significantly longer in group S patients (106 +/- 22 sec) than that of group F patients (49 +/- 18 sec, P < 0.001). CONCLUSIONS: With same dose, a slower rate of injection resulted in a lower incidence of myoclonus and can effectively reduce myoclonus without the use of a pretreatment agent.
Etomidate ; Humans ; Incidence ; Myoclonus ; Prospective Studies ; Unconsciousness

BACKGROUND: Etomidate injection is often associated with myoclonus. Etomidate injection technique influences the incidence of myoclonus. This study was designed to clarify which of the two injection techniques—slow injection or priming with etomidate—is more effective in reducing myoclonus. METHODS: This prospective randomized controlled study was conducted on 189 surgical patients allocated to three study groups. Control group (Group C, n = 63) received 0.3 mg/kg etomidate (induction dose) over 20 s. Priming group (Group P, n = 63) received pretreatment with 0.03 mg/kg etomidate, followed after 1 min by an etomidate induction dose over 20 s. Slow injection group (Group S, n = 63) received etomidate (2 mg/ml) induction dose over 2 min. The patients were observed for occurrence and severity of myoclonus for 3 min from the start of injection of the induction dose. RESULTS: The incidence of myoclonus in Group P (38/63 [60.3%], 95% CI: 48.0–71.5) was significantly lower than in Group C (53/63 [84.1%], 95% CI: 72.9–91.3, P = 0.003) and Group S (49/63 [77.8%], 95% CI: 66.0–86.4, P = 0.034). Myoclonus of moderate or severe grade occurred in significantly more patients in Group C (68.3%) than in Group P (36.5%, P < 0.001) and Group S (50.8%, P = 0.046), but the difference between Groups P and S was not significant (P = 0.106). CONCLUSIONS: Priming is more effective than slow injection in reducing the incidence of myoclonus, but their effects on the severity of myoclonus are comparable.
Etomidate ; Humans ; Incidence ; Myoclonus* ; Prospective Studies

For ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS), when surgery is not feasible, or in cases of severe biochemical disturbances, immunosuppression or mental instability, medical therapy with agents such as etomidate is indicated. We present our experience in using etomidate for a 41-year old female with EAS secondary to a malignant mediastinal paraganglioma. We were able to demonstrate that etomidate can be used effectively to control severe hypercortisolism in a lower dose than previously described.
Etomidate ; ACTH Syndrome, Ectopic ; Cushing Syndrome

BACKGROUND: Etomidate is a rapid-acting sedative/hypnotic agent with little or no cardiovascular effect and a high therapeutic index. For this reason, etomidate has been used as an anesthetic induction and maintenance agent in patients with poor cardiovascular reserve. Bispectral index (BIS), a parameter derived from electroencephalography (EEG), has been proposed as a measure of anesthetic effect and is shown to correlate with increasing sedation and loss of consciousness. To establish its utility for this purpose, it is important to determine the correlation among BIS, measured drug concentration, and increasing levels of sedation. This study was designed to evaluate this relation for etomidate. METHODS: Eighteen adult patients scheduled for elective surgery, ASA physical status I or II, were included. Etomidate was administerd until loss of consciousness (loss of verbal contact) using syringe pump with a constant rate (150 ml/h) and patients were observed until regaining consciousness as decided by prompt verbal response on command of "open your eyes". A BIS was monitored, arterial blood samples were obtained for analysis of drug concentration, and the patients were evaluated for level of sedation by the responsiveness portion of the modified observer's assessment of alertness/sedation (OAA/S) scale. RESULTS: The BIS (r = 0.86) correlated significantly with the OAA/S more than the etomidate plasma concentration (r = 0.57). The BIS values, OAA/S, and blood concentrations were 50, 1.26, and 1337 ng/ml at induction and 75, 4.6, and 236 ng/ml at awakening, respectively. CONCLUSIONS: We concluded that the BIS accurately predicted level of sedation with etomidate during anesthesia induction, but the correlation between blood concentration and level of sedation was less strong.
Adult ; Anesthesia* ; Anesthetics ; Consciousness ; Electroencephalography ; Etomidate* ; Humans ; Plasma ; Syringes ; Unconsciousness

BACKGROUND: Etomidate frequently induces myoclonus when administered intravenously with bolus injection during anesthetic induction. This can be bothersome for the anesthesiologist. The dose of remifentanil appropriate for preventing myoclonus without side effects was investigated. METHODS: All patients with American Society of Anesthesiologists (ASA) physical status I-III were divided into three groups (n = 33 per group) according to the pretreatment effect site concentration of remifentanil (Ultiva, Glaxo-Wellcome, Munchen, Germany) of 0, 2 or 4 ng/ml (Group N: 0 ng/ml, Group R: 2 ng/ml, Group Q: 4 ng/ml) by a target controlled infusion (TCI) system. After a 0.3 mg/kg dose of etomidate was injected intravenously for over 1 minute for anesthetic induction, myoclonus was observed. Before the etomidate injection, the patients were pretreated with remifentanil and their side effects were monitored. RESULTS: The number of patients showing myoclonus was significantly different among the groups. The incidence of myoclonus was 81%, 12% and 0% (groups N, R, and Q, respectively, P < 0.01). Side effects including bradycardia and hypotension did not occur in either Group R or Q. Chest wall rigidity occured in 45% of patients in Group Q. CONCLUSIONS: Administration with a 2 ng/ml effect site concentration of remifentanil could reduce the incidence of myoclonus caused by etomidate bolus injection without chest wall rigidity.
Bradycardia ; Etomidate ; Humans ; Hypotension ; Incidence ; Myoclonus ; Piperidines ; Thoracic Wall

BACKGROUND: Redistribution hypothermia can be modified by the effects of induction anesthesia on the systemic vascular resistance. This study compared the effects of etomidate and propofol on redistribution hypothermia during general anesthesia. METHODS: Forty patients were randomly allocated into one of two groups, based on the induction agent used: Group E (n = 20) received 0.2 mg/kg of etomidate and group P (n = 20) received 2.5 mg/kg propofol. After intubation, anesthesia was maintained with sevoflurane and 50% nitrous oxide in oxygen in both groups. The core and peripheral temperatures were measured, and the peripheral temperature gradients (forearm minus fingertip) were used as an index of an arteriovenous shunt. RESULTS: The patients in both groups demonstrated intense vasoconstriction prior to the induction of anesthesia with similar skin-temperature gradients. After induction, group P showed more rapid and significant vasodilation than group E (P = 0.02). The difference in vasodilation between the two groups disappeared from 5 minutes after intubation. The pre-induction core temperatures were similar in both groups. After induction, the core temperatures in group P were consistently lower than those in group E (P < 0.01). The core temperatures during the first hour of anesthesia decreased by 1.5 +/- 0.4 degrees C in group P but only by 0.9 +/- 0.4 degrees C in group E. Conclusions: Propofol caused more rapid and aggravated redistribution hypothermia during surgery than etomidate due to the earlier arteriovenous shunt vasodilation.
Anesthesia ; Anesthesia, General* ; Etomidate* ; Humans ; Hypothermia* ; Intubation ; Nitrous Oxide ; Oxygen ; Propofol* ; Vascular Resistance ; Vasoconstriction ; Vasodilation

BACKGROUND: Etomidate is frequently used as an induction agent in the elderly patients. We compared the induction dose of etomidate in the elderly patients. METHODS: Sixty ASA 1-2 patients were randomly allocated to four groups. They were Group 1 (age < 65, receiving 0.2 mg/kg of etomidate, n = 15), Group 2 (age < 65, receiving 0.3 mg/kg of etomidate, n = 15), Group 3 (age > or = 65, receiving 0.2 mg/kg of etomidate, n = 15), and Group 4 (age > or = 65, receiving 0.3 mg/kg of etomidate, n = 15). The time interval from etomidate infusion to loss of verbal response and eyelash reflex, to decrease BIS 50, to return of bispectral index (BIS) 50 were measured. Mean arterial pressure (MAP), heart rate (HR), responses to isolated forearm test and postoperative recall were recorded. RESULTS: Time interval were not significantly different between groups. BIS value did not show statistical differences between groups, though value of group 1 at 1 min after intubation was higher than that of group 2. MAP and HR were increased after intubation in 4 groups. The changes in MAP were significantly different between group 1 and 2. Isolated forearm test was positive in 10, 6, 4, 3 patients in groups 1, 2, 3 and 4, respectively. Only 1 patient in group 1 showed postoperative recall. CONCLUSIONS: Age does not influence the BIS value in these etomidate doses. Loss of consciousness and hemodynamic changes during induction with 0.2 mg/kg of etomidate were inappropriate in younger patients, whereas they were appropriate with 0.2 and 0.3 mg/kg of etomidate in the elderly patients.
Aged* ; Anesthesia, General* ; Arterial Pressure ; Etomidate* ; Forearm ; Heart Rate ; Hemodynamics ; Humans ; Intubation ; Reflex ; Unconsciousness

PURPOSE: The use of rapid sequence intubation (RSI) by emergency physicians in emergency departments is increasing. Our aim was to evaluate the current practice of RSI, focusing particularly on the appropriateness of sedative dose. METHODS: We retrospectively investigated RSI cases in two urban emergency centers occurring between June 2005 and May 2006. We calculated the sedative dose used per patients' weight and divided into a low dose group (less than the minimum recommended dose) and a full dose group. We investigated the differences between these two groups, including hemodynamic changes, success rates and complication rates. RESULTS: Of 745 cases of endotracheal intubation performed, 211 cases were defined as RSI cases. The mean sedative dose was 0.29 mg/kg (+/-0.08 SD) for etomidate and 0.08 mg/kg (+/-0.03 SD) for midazolam. Sedatives were underdosed in 56.3% of etomidate cases and 82.1% of midazolam cases, for a mean underdose rate of 63.6%. Drops in SBP (systolic blood pressure) were significantly different between the etomidate and midazolam groups (-14.4 mmHg vs -22.43 mmHg, p=0.04), but there was no significant difference in SBP between low dose and full dose groups. The overall complication rate was 17.1%, was again with no significant difference between full dose and low dose groups. CONCLUSION: Overall, sedatives were underdosed in 63.6% of cases with midazolam more frequently underdosed than etomidate. However, the underdosing of sedatives was not significantly correlated with the first pass rate or the complication rate.
Emergencies* ; Emergency Service, Hospital ; Etomidate ; Hemodynamics ; Hypnotics and Sedatives* ; Intubation ; Intubation, Intratracheal ; Midazolam ; Observational Study* ; Retrospective Studies*

BACKGROUND: There have been no previous studies on the effect of anesthetic agents on rhinovirus (RV) infection, which is the most common pathogen of the common cold in human airway epithelial cells. We investigated the effects of propofol and etomidate on the airway epithelial cells infected with RV. METHODS: RV-infected A549 cells were treated with propofol and etomidate for 24 hours. On the third day of infection, cells and supernatant were collected to measure the intercellular adhesion molecule-1 (ICAM-1) expression, viral titer and the amount of cytokine. The extents of the viral replication were expressed as viral titers by 50% tissue culture infection dose (TCID50). RESULTS: The ICAM-1 expression of the groups treated with propofol 1, 10, 100micrometer vs etomidate 1, 5, 25micrometer were 15.6 +/- 4.2, 16.4 +/- 3.7, 14.1 +/- 4.7% vs 16.8 +/- 5.7, 16.4 +/- 5.3, 17.2 +/- 4.5%, but there were not significantly different among subgroups. Productions of cytokines were increased after RV-infection, but there were not significantly different among the propofol and etomidate treated subgroups. The viral titers of the groups treated with propofol and etomidate were not significantly different among subgroups either. CONCLUSIONS: Propofol and etomidate had no effect on the replication of RV and the cytokine release after RV infection in human airway epithelial cells.
Anesthetics ; Common Cold ; Cytokines ; Epithelial Cells ; Etomidate ; Humans ; Intercellular Adhesion Molecule-1 ; Propofol ; Rhinovirus