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: 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

BACKGROUND: Etomidate frequently induces myoclonus, so it may affect electromyographics (EMG). And EMG commonly has an effect on the bispectral index scale (BIS) and spectral entropy. This study was performed to compare the effect of etomidate on BIS, response entropy (RE) and state entropy (SE) during induction of anesthesia. METHODS: Fifty patients (ASA I or II) scheduled for elective surgery were included in this study. Anesthesia was induced with etomidate (0.3 mg/kg) and rocuronium (0.6 mg/kg). Patients also inhaled 4 vol% sevoflurane and 100% oxygen and, then intubated. BIS, RE, SE and Modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S) were measured 4 times (before injection of etomidate [T0], at loss of eyelash reflex [T1], 90 seconds after rocuronium injection [T2], and after intubation [T3]). We also checked whether myoclonus occurred. RESULTS: Baseline values (T0) were 93.1 +/- 4.7 for BIS, 95.8 +/- 3.7 for RE and, 87.3 +/- 3.5 for SE. In comparison with T0, there were significantly differences in BIS (50.2 +/- 16.3), RE (76.8 +/- 18.5) and SE (66.3 +/- 17.4) at T1 (all P < 0.05). There were no significant differences at T2 and T3. Thirty one patients had myoclonus. At the occurrence of myoclonus, RE and SE values significantly increased but not BIS (P < 0.05). CONCLUSIONS: In patients with myoclonus, at the loss of consciousness, spectral entropy did not decrease where as BIS did, suggesting that BIS may evaluate hypnotic levels better than spectral entropy during induction of anesthesia with etomidate.
Androstanols ; Anesthesia ; Electromyography ; Entropy ; Etomidate ; Humans ; Intubation ; Methyl Ethers ; Myoclonus ; Oxygen ; Reflex ; Unconsciousness

BACKGROUND: This study compared intubating conditions and the onset time associated with administration of cisatracurium, a nondepolarizing neuromuscular blocker with a relatively slow onset, according to prior injection of one of two intravenous anesthetic agents: propofol or etomidate. METHODS: Forty-six female patients, undergoing general anesthesia and endotracheal intubation for elective surgery, were randomized to two groups; group P were administered propofol (2 mg/kg) prior to cisatracurium (0.2 mg/kg); group E were administered etomidate (0.3 mg/kg) prior to cisatracurium (0.2 mg/kg). We measured intubating conditions and the onset time according to the types of intravenous anesthetic administered. Measurements of heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were taken immediately prior to induction; immediately and 1 min after IV anesthetic administration; and immediately and 1, 2, 3, 4, 5, 7, and 15 min after endotracheal intubation. RESULTS: Intubating conditions were superior in group E compared with group P (P = 0.009). The average onset time of cisatracurium was more rapid in group E (155.74 +/- 32.92 s vs. 185.26 +/- 38.57 s in group P; P = 0.008). There were no group differences in SBP, DBP, and HR following intravenous anesthetic drug injection and endotracheal intubation. However, SBP and DBP were substantially higher in group E after endotracheal intubation. CONCLUSIONS: Etomidate improves intubating conditions and provide a more rapid onset time of cisatracurium during anesthetic induction compared to propofol.
Anesthesia, General ; Anesthetics ; Blood Pressure ; Etomidate* ; Female ; Heart Rate ; Humans ; Intubation, Intratracheal ; Neuromuscular Blockade ; Propofol*

BACKGROUND: Many studies have suggested that propofol in combination with remifentanil may provide adequate conditions for tracheal intubation without the use of muscle relaxants. Other hypnotic drugs have not been thoroughly investigated in this regard. The goal of our study was to evaluate the effect of thiopental, propofol or etomidate on tracheal intubating conditions and hemodynamic changes using remifentanil in the absence of muscle relaxants. METHODS: A total of 45 healthy adults were divided randomly into three groups. After iv lidocaine 1.5 mg/kg, thiopental 5 mg/kg (thiopental group) or propofol 2.5 mg/kg (propofol group), or etomidate 0.4 mg/kg (etomidate group) were injected. After the injection of study drugs, remifentanil 2 mcg/kg was administered. Ninety seconds after the administration of remifentanil, laryngoscopy and intubation were attempted. Intubating conditions were assessed and the mean arterial pressure and the heart rate was measured. RESULTS: There were no significant differences in intubating conditions between patients in the three groups. The heart rate was significantly lower in the propofol and etomidate group patients when compared to the thiopental group patients after anesthetic induction. The mean arterial pressure was significantly lower in the propofol group patients when compared to the thiopental and etomidate group patients. Both heart rate and mean arterial pressure after tracheal intubation were significantly elevated in etomidate group patinets when compared to their preintubation value. CONCLUSIONS: The use of thiopental 5 mg/kg, propofol 2.5 mg/kg, and etomidate 0.4 mg/kg did not differ in effect under intubating conditions for tracheal intubation using remifentanil in the absence of muscle relaxants. Thiopental provided the best hemodynamic conditions.
Adult ; Arterial Pressure ; Etomidate* ; Heart Rate ; Hemodynamics* ; Humans ; Intubation* ; Laryngoscopy ; Lidocaine ; Propofol* ; Thiopental*