Original Contribution
Etomidate for procedural sedation in the elderly: a retrospective comparison between age groups,☆☆

https://doi.org/10.1016/j.ajem.2010.08.004Get rights and content

Abstract

Objective

The objective of the study was to compare the complication rate and length of stay (LOS) between the elderly (65 years and older) and the adult (18-64 years old) populations when etomidate is used for procedural sedation in the emergency department (ED).

Methods

A retrospective analysis was performed. Electronic medical records selected all patients who received etomidate in the ED from June 2004 to June 2008. Patients younger than 18 years and those who were intubated were excluded. To account for correlated errors, only first-time visits to the ED were used.

Results

There were 31 (16%) patients who experienced a complication: 9 (20%) elderly patients compared with 22 (14.8%) adult patients. No significant difference existed between the age groups and adverse effects. The adult mean LOS was 205 minutes, and the elderly LOS was 225 minutes. There was no significant difference between age groups and adverse effects when compared with LOS. Among patients who experienced a complication, mean LOS was 267 minutes: 252 minutes in the elderly age group and 273 minutes in the adult. Among patients who did not experience a complication, the mean LOS in the elderly and adult age groups was 219 and 193 minutes, respectively, with an overall LOS of 199 minutes. There was a statistical significance (P ≤ .05) between adverse effect and LOS. Patients who experienced a complication remained in the ED for 68 more minutes.

Conclusion

Etomidate remains as safe and effective an alternative for procedural sedation in the elderly as it is in the general aged population.

Introduction

Etomidate has become an important tool in the arsenal of today's emergency physician. It is being used in a variety of scenarios for both intubation and procedural sedation. Physicians enjoy its quick onset and short duration of action along with the minimal hemodynamic effects. It has been shown to be superior to midazolam not only in causing significantly fewer episodes of hypotension when used as an induction agent in rapid sequence intubation [1], but also in procedural sedation and analgesia when used for anterior shoulder dislocations [2]. Etomidate has been deemed an appropriate agent for procedural sedation in the emergency department [ED] [3].

As with any drug, however, etomidate is not without its adverse effects. Etomidate significantly increased mortality rates of ICU trauma patients when it was used as a continuous infusion for sedation [4]. Despite inhibition of the adrenal mitochondrial hydroxylase activity, frank adrenal suppression has long been debated; and multiple articles have discussed the possible detrimental effects etomidate can have in patients in septic shock [5], [6], [7], [8]. The adrenal effects remain unclear even after a single dose of etomidate [9], [10]. Other adverse effects that have been reported are apnea, emesis, desaturation, myoclonus, bradycardia, and emergency anxiety [11], [12], [13], [14].

Etomidate for procedural sedation has become a common drug among emergency physicians because of its relatively safe adverse effect profile. It has been used in all age groups with success. With the appearance of an ever-increasing number of elderly patients in the ED, emergency physicians must be careful with their use of sedatives and analgesics. It is the goal of this study to compare the adverse effects and length of stay (LOS) between the elderly population (65 years and older) and the general adult population (18-64 years old) when etomidate is used for procedural sedation. Specifically, our hypothesis is that using etomidate in the elderly population does not lead to more adverse effects or a longer LOS in the ED.

Section snippets

Methods

We performed a 4-year retrospective analysis of ED patients who received etomidate for procedural sedation from June 1, 2004, to June 16, 2008. The ED is an urban setting teaching hospital on the north side of Chicago with an annual ED volume of 55 000 patients.

We used electronic medical records to select all patients who received etomidate in the ED over the time frame. Because the study design focused only on procedural sedation of adults, all patients younger than 18 years and those who

References (17)

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Oral presentation was given at the 2009 American College of Osteopathic Emergency Physicians Fall Scientific Assembly in Boston, MA, September 30, 2009.

☆☆

Poster presentation was given at the 2010 Illinois College of Emergency Physicians Spring Symposium at Northwestern Memorial Hospital, Chicago, IL, April 29, 2010.

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