What is the recommended dose of etomidate (amidate) for rapid sequence intubation (RSI) in a patient?

Etomidate Dosing for Rapid Sequence Intubation

The recommended dose of etomidate for rapid sequence intubation is 0.3 mg/kg IV, administered over 30-60 seconds, as specified by the FDA label and endorsed by the Society of Critical Care Medicine guidelines. 1, 2

Standard Dosing Protocol

• Administer etomidate 0.3 mg/kg IV as the standard induction dose for RSI in adult patients and pediatric patients above 10 years of age. 1, 3
• The dose range approved by the FDA is 0.2-0.6 mg/kg, but 0.3 mg/kg represents the usual dose that balances efficacy with safety. 1
• Inject the medication over 30-60 seconds to optimize onset while minimizing adverse effects. 1

Dose Modifications for Hemodynamically Compromised Patients

• In patients with hemodynamic instability, reduce the dose to 0.15 mg/kg to minimize cardiovascular effects while maintaining adequate sedation. 3, 2
• This lower dose has been studied in prehospital settings and maintains effectiveness for intubation while providing an additional safety margin. 3

Critical Dosing Pitfalls to Avoid

• Do not exceed 0.3 mg/kg in elderly patients (>55 years) or those with respiratory compromise, as doses ≥0.23 mg/kg in this population are associated with oxygen desaturation requiring bag-assisted ventilation. 2
• Patients weighing ≥100 kg are at high risk for under-dosing—a retrospective study found 68% of patients ≥100 kg received subtherapeutic doses (<0.2 mg/kg) compared to only 2% of patients <100 kg. 4
• Calculate the actual dose in milligrams based on body weight; do not use fixed dosing or round down excessively in heavier patients. 4

Neuromuscular Blocking Agent Requirement

• Always administer a neuromuscular blocking agent (succinylcholine 1-1.5 mg/kg or rocuronium 0.9-1.2 mg/kg) immediately after etomidate to prevent awareness during paralysis and optimize intubating conditions. 3, 2
• The Society of Critical Care Medicine strongly recommends against using sedative-hypnotic agents alone without neuromuscular blockade for RSI. 3

Hemodynamic Profile and Safety

• Etomidate provides superior hemodynamic stability compared to other induction agents, with minimal effects on blood pressure and heart rate even in critically ill patients. 5, 6
• The Society of Critical Care Medicine guidelines found no mortality difference between etomidate and other induction agents (OR 1.17; 95% CI 0.86-1.60) in critically ill adults undergoing RSI. 3, 2

Adrenal Suppression Controversy

• Do not administer corticosteroids following single-dose etomidate for RSI—multiple randomized controlled trials demonstrated no mortality benefit from prophylactic hydrocortisone administration. 3, 2
• While etomidate causes transient biochemical adrenal suppression (OR 2.43; 95% CI 1.67-3.53), this has not translated to increased mortality or clinically significant adverse outcomes in critically ill patients. 2
• One trauma study found increased ICU length of stay (6.3 vs 1.5 days) and ventilator days (28 vs 17 days) with etomidate compared to fentanyl/midazolam, but this single-center study conflicts with larger multicenter data showing no mortality difference. 7, 3

Onset and Duration

• Onset of action occurs within 5-15 seconds after IV administration, providing rapid induction for emergency airway management. 5
• Duration of action is 5-15 minutes, which is appropriate for the intubation procedure. 5

Common Side Effects to Anticipate

• Myoclonic movements occur during induction but do not interfere with intubation success. 5
• Pain on injection can be minimized by using larger veins and avoiding small hand veins. 5
• Nausea and vomiting occur in approximately 4-10% of patients. 2, 8