ETOMIDATE-LIPURO 2MG ML 10ML Ampoules 10'S

ETOMIDATE-LIPURO contains etomidate in a lipid emulsion formulation. Etomidate is an imidazole derivative that enhances GABA-A receptor activity (similar to propofol), producing rapid loss of consciousness without significant cardiovascular or respiratory depression.

The lipid emulsion (Lipuro) formulation reduces the venous pain associated with the older propylene glycol-based formulation.

Etomidate is indicated for the induction of general anaesthesia, particularly in patients with compromised cardiovascular reserve or haemodynamic instability, where minimal cardiovascular depression is essential. It is the induction agent of choice in: cardiovascular surgery patients with low ejection fraction; trauma patients with haemorrhagic shock; septic shock patients requiring emergency intubation; and elderly patients with ischaemic heart disease.

Unlike propofol, etomidate maintains heart rate, blood pressure, and cardiac output during induction, making it uniquely valuable in high-risk anaesthesia settings. It is also used for procedural sedation in ICU and emergency settings.

Etomidate is administered as a rapid intravenous injection by trained anaesthetists or emergency physicians only. It must not be self-administered.

Induction of Anaesthesia

•       Standard induction dose: 0.2–0.3 mg/kg IV over 30–60 seconds.

•       Elderly or ASA III/IV patients: start at lower end (0.15–0.2 mg/kg).

•       Onset of anaesthesia: within 60 seconds.

•       Duration of anaesthesia: 4–10 minutes (single induction dose).

Pre-medication

Pre-oxygenation is mandatory before rapid sequence induction. An opioid (fentanyl 1–2 mcg/kg) given 1–2 minutes before etomidate reduces the dose of induction agent required, blunts laryngoscopy responses, and reduces involuntary myoclonic movements. Benzodiazepine pre-medication also reduces myoclonus.

Procedural Sedation (ICU/Emergency)

•       0.1–0.2 mg/kg IV for brief procedural sedation.

•       Not recommended for prolonged sedation due to adrenal suppression risk.

Common Side Effects

•       Myoclonus (involuntary muscle movements during induction) — occurs in up to 70% of patients; not a sign of seizure; reduced by fentanyl or benzodiazepine pre-medication.

•       Nausea and vomiting on recovery — higher incidence than propofol; consider prophylactic antiemetics.

•       Pain on injection — significantly reduced with Lipuro lipid emulsion formulation.

Critical Side Effect — Adrenal Suppression

Etomidate inhibits 11-beta-hydroxylase, blocking cortisol and aldosterone synthesis. Even a single induction dose causes transient adrenal suppression lasting 12–24 hours. This is clinically significant in critically ill patients (sepsis, trauma) where cortisol response is crucial for haemodynamic stability.

•       In septic patients: single-dose etomidate for RSI may be associated with increased mortality due to relative adrenal insufficiency — some evidence suggests hydrocortisone supplementation should be considered after etomidate use in septic shock.

Laryngeal Reflex Activity

•       Etomidate does not abolish laryngeal reflexes as effectively as propofol — supplement with adequate opioid or muscle relaxant.

Adrenal Suppression in Critically Ill Patients

The adrenal suppression from a single etomidate induction dose is transient (12–24 hours) and clinically insignificant in healthy surgical patients. However, in patients with pre-existing septic shock, major trauma, or adrenal insufficiency, this suppression can precipitate haemodynamic deterioration. Consider stress-dose hydrocortisone (200 mg/day in divided IV doses) after etomidate use in septic patients who remain vasopressor-dependent.

Myoclonus Management

Myoclonic movements during induction can interfere with intubation and may alarm the patient's family. They are benign. Reduction strategies: fentanyl 1–2 mcg/kg given 90 seconds before etomidate; midazolam 0.03 mg/kg given 2 minutes before; or using a slightly slower injection rate.

Egg and Soy Allergy

The Lipuro emulsion contains purified egg phospholipids and soybean oil. In patients with severe egg or soy allergies, use with caution. Cross-reactivity between egg allergy and the purified phospholipid emulsion is theoretically possible but rare — assess the severity of the allergy and weigh against clinical urgency.

•       CNS depressants (opioids, benzodiazepines, propofol, volatile anaesthetics) — additive sedation/anaesthesia; dose reduction of etomidate or co-administered agents may be required.

•       Fentanyl — intentional combination; reduces myoclonus and blunts response to laryngoscopy; reduces required etomidate dose.

•       Verapamil — may prolong anaesthetic effect.

•       Neuromuscular blocking agents (suxamethonium, rocuronium) — routinely combined for rapid sequence intubation; no pharmacokinetic interaction.

•       Store below 25 degrees Celsius. Do not freeze.

•       Protect from light.

•       Single-use ampoule — discard unused portion after use.

•       The lipid emulsion should appear milky white — do not use if discoloured or if phase separation is visible.

•       Keep out of reach of children.

Etomidate-Lipuro is a hospital-use-only, prescription-only medicine (POM) in Kenya. It is used exclusively by anaesthetists, intensivists, and emergency physicians in operating theatres, ICUs, and emergency departments.

It must only be administered by or under the direct supervision of a qualified anaesthetist or critical care physician.

Indications for Choosing Etomidate Over Propofol

•       Haemodynamically unstable patients (trauma, sepsis, cardiogenic shock): etomidate preserves blood pressure; propofol causes significant hypotension.

•       Low ejection fraction (EF below 30%) cardiac patients: etomidate is the preferred induction agent.

•       Elderly frail patients with cardiovascular disease: etomidate was tolerated better.

•       Patients with known propofol sensitivity: etomidate is a safe alternative.

Limitations vs Propofol

•       Higher incidence of post-operative nausea and vomiting — always add prophylactic antiemetic (ondansetron 4 mg IV).

•       Higher myoclonus rate — pre-medicate as above.

•       Cannot be used for TIVA (Total Intravenous Anaesthesia) or prolonged sedation — adrenal suppression risk.

•       Does not provide analgesia — combine with an opioid.

Adrenal Supplementation Protocol in Sepsis

Where etomidate is used for RSI in septic shock (Surviving Sepsis Campaign context): if the patient remains vasopressor-dependent at 6–12 hours post-intubation, consider empirical stress-dose hydrocortisone 50 mg IV every 6 hours (or 200 mg/day continuous infusion) while awaiting cortisol stimulation test results.

Why is etomidate preferred for patients with heart problems?

Etomidate has a minimal effect on heart rate, blood pressure, and heart muscle contractility, unlike propofol, which commonly causes a significant fall in blood pressure. This makes etomidate the preferred induction agent for patients with poor heart function, low blood pressure, or who are in shock. This cardiovascular stability is its defining clinical advantage.

What are the muscle twitches I might experience during induction?

The involuntary muscle jerking (myoclonus) that occurs with etomidate is a common pharmacological effect seen in up to 70% of patients. It is not dangerous and does not indicate a seizure. The movements usually stop as anaesthesia deepens. Giving a small amount of fentanyl or a benzodiazepine before etomidate significantly reduces this effect.

What is adrenal suppression, and why does it matter with etomidate?

The adrenal glands produce cortisol, a hormone essential for the body's stress response. Etomidate temporarily blocks cortisol production for 12–24 hours after a single dose. In most patients, this short-term effect is harmless. However, in very sick patients (especially those in septic shock), this temporary drop in cortisol production can worsen low blood pressure. In these cases, doctors may give supplemental hydrocortisone (a steroid) after etomidate to compensate.