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Three Part Question

In [adult patients requiring procedural sedation for an orthopaedic manipulation] is [intravenous etomidate] an [effective drug to consider using to provide safe effective sedation].

Clinical Scenario

A thirty four year old man attends the emergency department with an anterior dislocation of his right shoulder. You are wondering what drug to use to provide procedural sedation and wonder if you should consider using etomidate.

Search Strategy

Medline 1950 to June 2008 week 1 via OVID interface.
{Etomidate.MP} AND
{Sedation .MP} AND
{emergency ADJ department .TI OR Manipulation .mp OR Shoulder .mp}
AND Limit to human and English Language.

Search Outcome

The search strategy returned 23 papers, of these five where both relevant to the three part question and of sufficient quality.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Miner JR. Danahy M. Moch A. Biros M. Jan 2007 USA	214 patients randomized to propofol or Etomidate	Prospective, randomized trial.	Both drugs equally safe, myoclonus reported in 20% of cases recieving etomidate	Propofol better success rate: -7.4%; 95% CI -14.3% to -1.1%)	Not blinded.
Burton JH. Bock AJ. Strout TD. Marcolini EG. 2002 Nov. USA	46 adult patients with anterior shoulder dislocation. 22 received etomidate and 24 midazolam.	Prospective, randomized, double blinded controlled trial.	Etomidate equally safe and effective.	Significantly reduced wakening time with etomidate.	Small sample size. Fixed dose drug regieme.
Sacchetti A. Senula G. Strickland J. Dubin R. Jan 2007 USA	1028 Emergency department patients in community emergency department. Patients receiving a range of painful procedures most frequently shoulder relocation (392). 241 patients received etomidate, 423 recieved midazolam, 253 recieved propofol.	Prospective, multi centre observational study.	6.2% overall complication rate with etomidate compared to midazolam 6.4% and propofol 0.8%		None randomized. No control.
Miner JR. Martel ML. Meyer M. Reardon R. Biros MH. 2005 Feb USA	62 ASA grade 3 or 4 patients receiving procedural sedation in the emergency department.	Non - randomized prospective cohort study.	Etomidate and propofol equally safe.		Drug given at choice of treating physician.

Comment(s)

Alternative drugs for procedural sedation have been proposed for some time. Propofol has been compared favourably to midazolam although several other drugs have been proposed. Etomidate has been shown to have similar efficacy to both propofol and midazolam at providing procedural sedation. Etomidate also offers the advantage of a reduced wakening time similar to that offered by propofol.

Clinical Bottom Line

Etomidate can be safely and effectively used to provide procedural sedation and offers a clinical advantage with reduced time to wakening.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Miner JR. Danahy M. Moch A. Biros M. Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department. Annals of Emergency Medicine. 2007 Jan. 49(1):15-22
2. Burton JH. Bock AJ. Strout TD. Marcolini EG. Etomidate and midazolam for reduction of anterior shoulder dislocation: a randomized, controlled trial. Annals of Emergency Medicine. 2002 Nov. 40(5):496-504.
3. Sacchetti A. Senula G. Strickland J. Dubin R. Procedural sedation in the community emergency department: initial results of the ProSCED registry. Academic Emergency Medicine. 2007 Jan. 14(1):41-6,
4. Miner JR. Martel ML. Meyer M. Reardon R. Biros MH. Procedural sedation of critically ill patients in the emergency department. Academic Emergency Medicine. 2005 Feb. 12(2):124-8