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Class: General Anesthetics, Miscellaneous
VA Class: CN203
Chemical Name: 1-(1-Phenylethyl)-1H-imidazole-5-carboxylic acid ethyl ester
Molecular Formula: C14H16N2O2
CAS Number: 33125-97-2
Brands: Amidate

Medically reviewed by Last updated on Oct 21, 2019.


Sedative and hypnotic agent used for general anesthesia.1 2 3 4 5 756 765

Uses for Etomidate

Induction of Anesthesia

Used for induction of general anesthesia.1 2 3 4 5 Induction results in dose-related hypnotic effects (progressing from light sleep to unconsciousness).1 2 3 4 5 6 9

Particularly useful in patients with compromised cardiopulmonary function because of minimal hemodynamic effects and decreased respiratory depressant effects relative to other IV anesthetics (e.g., barbiturates, propofol).a

Carefully weigh potential benefits of the drug’s hemodynamic effects against possible risk of myoclonus.1 2 774 (See Common Adverse Effects under Cautions.)

Maintenance of Anesthesia

May be used during maintenance of anesthesia to supplement subpotent anesthetic agents (e.g., nitrous oxide and oxygen) during short surgical procedures (e.g., dilatation and curettage, cervical conization).1 2 Use for longer procedures not recommended due to risk of prolonged adrenal suppression.1 2 (See Adrenal Suppression under Cautions.)

Rapid Sequence Intubation

Commonly used for rapid sequence intubation because of rapid onset of action and favorable hemodynamic profile.12 754 755 761 765 767 768 772 773 However, risk of adrenal suppression may limit use in critically ill patients (particularly those with sepsis).12 766 767 769 774

Procedural Sedation

Has been used for procedural sedation.756 757 758 759 760 763 821 822 823 Because of its short duration of action, the drug is best suited for short procedures.756 759

Time to onset of sedation and recovery with etomidate are comparable to those achieved with propofol, but considerably shorter than with midazolam.758 760 761 762 763 822 However, etomidate is associated with increased risk of myoclonus and pain at the injection site compared with other sedative agents.758 760 761 821 Although respiratory depression or apnea reported in some patients, incidence is generally the same or less than with other sedative agents.756 760 761 763 765

Etomidate Dosage and Administration


Administration Precautions

Administer only by individuals experienced in the use and management of possible complications of general anesthetic agents.1 2 764 770 771 823


  • May administer premedications such as benzodiazepines (to relieve anxiety and produce anterograde amnesia) and opiate agonists (to relieve pain) as appropriate.1 2 9 10


Administer by IV injection.1

May be administered by intraosseous (IO) injection in the setting of pediatric rapid sequence intubation.13

Has been administered by continuous IV infusion; however, this method of delivery is not recommended because of risk of adrenal toxicity.1 2 6 765 (See Adrenal Suppression under Cautions.)

Limited data indicate that inadvertent intra-arterial administration of etomidate injection does not appear to be associated with tissue necrosis distant from the injection site; however, intra-arterial use of the drug is not recommended.1 2 9

IV Administration

Administer undiluted by direct IV injection.1 2 10

Administer into larger, more proximal, veins of the forearm, rather than the smaller, distal hand or wrist veins to minimize pain at injection site.1 2

To prevent needlestick injuries, do not recap, bend, or break needles by hand.1 2

Rate of Administration

For induction of anesthesia, administer by rapid (over 30–60 seconds) IV injection in children >10 years of age and adults.1 2


Because individual response is variable, adjust dosage according to individual requirements and response, age, physical and clinical status, underlying pathologic conditions (e.g., shock, intestinal obstruction, malnutrition, anemia, burns, advanced malignancy, ulcerative colitis, uremia, alcoholism), and the type and amount of premedication or concomitant medication(s).1 2 9 Titrate dosage according to clinical effect.9

Pediatric Patients

Induction of Anesthesia

Children >10 years of age: 0.3 mg/kg (0.2–0.6 mg/kg).1 2 9

Maintenance of Anesthesia

Use smaller increments than those used for induction.1 2

Rapid Sequence Intubation
IV or IO

Manufacturers state inadequate data to make dosage recommendations for pediatric patients <10 years of age.1 2 In published reports, average dose of 0.3 mg/kg has been used in pediatric patients as young as 18 days of age.772 773

Some clinicians recommend a dose of 0.3 mg/kg by IV or IO injection for pediatric rapid sequence intubation.13

Procedural Sedation

Doses are usually less than those used for induction of anesthesia; in clinical studies, initial etomidate dose of 0.1–0.2 mg/kg usually administered, followed by additional doses of 0.05–0.1 mg/kg as needed (average total dose of up to 0.26 mg/kg per procedure).756 758 759 760 761 762 763

Some studies have found that a dose of 0.2 mg/kg was most effective initial dose for short pediatric procedures in the emergency department.756


Induction of Anesthesia

0.3 mg/kg (0.2–0.6 mg/kg).1 2 9

Maintenance of Anesthesia

Use smaller increments than those used for induction.1 2

Rapid Sequence Intubation

Usual dose of 0.3 mg/kg.12 754 755 768

Procedural Sedation

Doses are usually less than those used for induction of anesthesia; in clinical studies, initial etomidate dose of 0.1–0.2 mg/kg usually administered, followed by additional doses of 0.05–0.1 mg/kg as needed (average total dose of up to 0.26 mg/kg per procedure).756 758 759 760 761 762 763

Special Populations

Geriatric Patients

Geriatric patients may require lower dosages than younger patients because of pharmacokinetic differences (e.g., reduced protein binding and reduced clearance).2 765

Cautions for Etomidate


  • Known hypersensitivity to etomidate.1 2


Administration Precautions

To minimize risk of adverse effects, follow recommendations for administration and monitoring of etomidate therapy.1 (See Dosage and Administration.)

Adrenal Suppression

Causes adrenal suppression by inhibiting 11-β-hydroxylase activity, the enzyme responsible for production of cortisol and aldosterone.1 766 768

Decreased plasma concentrations of cortisol (which usually persist for 6–8 hours and are unresponsive to stimulation by corticotropin [ACTH]) reported following IV administration of a single 0.3-mg/kg induction dose.1 2 3 4 5 6 768

Because of risk of prolonged adrenal suppression, do not administer as a continuous IV infusion.1 2 6

Although it is well established that etomidate causes adrenal suppression, there is controversy regarding the clinical importance.12 766 767 768 While evidence from one study showed increased mortality in critically ill patients (e.g., sepsis patients), other studies have not found such an association.766 767 768 769 774

Specific Populations


No adequate and well controlled studies in pregnant women; reduced pup survival and maternal toxicity observed in animal reproduction studies.1

Based on animal data, repeated or prolonged use of general anesthetics and sedation drugs, including etomidate, during the third trimester of pregnancy may result in adverse neurodevelopmental effects in the fetus.750 753 (See Pediatric Use under Cautions and also see Advice to Patients.)

Insufficient data to support use during labor and delivery; not recommended for obstetric use (e.g., cesarean section).1 2


Not known whether etomidate is distributed into milk.1 2 Use with caution.1 2

Pediatric Use

Manufacturers state safety and efficacy not established in children <10 years of age.1 2 10 However, the drug has been used for rapid sequence intubation in pediatric patients as young as 18 days of age.772 773 Also has been used in children of all ages for procedural sedation in the emergency department.756 757 758 759 762

Repeated or prolonged use of general anesthetics and sedation drugs, including etomidate, in children <3 years of age or during the third trimester of pregnancy may adversely affect neurodevelopment.750 753 In animals, use for >3 hours of anesthetic and sedation drugs that block N-methyl-d-aspartic acid (NMDA) receptors and/or potentiate GABA activity leads to widespread neuronal apoptosis in the brain and long-term deficits in cognition and behavior;750 751 752 753 clinical relevance to humans is unknown.750

Some evidence suggests similar deficits may occur in children following repeated or prolonged exposure to anesthesia early in life.750 752 Some evidence also indicates that a single, relatively brief exposure to general anesthesia in generally healthy children is unlikely to cause clinically detectable deficits in global cognitive function or serious behavioral disorders.750 751 752 Most studies to date have substantial limitations; further research needed to fully characterize effects, particularly for prolonged or repeated exposures and in more vulnerable populations (e.g., less healthy children).750

Consider benefits and potential risks when determining the timing of elective procedures requiring anesthesia.750 FDA states that medically necessary procedures should not be delayed or avoided.750 753 (See Advice to Patients.)

Geriatric Use

Cardiac depression (decreased heart rate and cardiac index) and decreased mean arterial BP may occur in geriatric patients receiving etomidate, especially in those with hypertension.2

Since geriatric patients may have decreased renal function, monitor renal function and select dosage carefully.2 (See Special Populations under Dosage and Administration and see Renal Impairment under Cautions.)

Hepatic Impairment

Metabolized by the liver; patients with hepatic insufficiency may be at higher risk of adverse effects (e.g., adrenal insufficiency).774

Renal Impairment

Substantially excreted by the kidneys.2 Risk of severe adverse reactions may be increased in patients with impaired renal function.2

Common Adverse Effects

Injection site pain, skeletal muscle movements (e.g., myoclonic, averting, tonic, or ocular movements), postoperative nausea and vomiting. 1 2 3 4 9 758 760 761 821

Myoclonus occurs frequently.1 2 758 760 761 821 Most episodes are mild to moderate in severity, although disturbing movements reported occasionally.1 2 Usually bilateral.1 2 Administration of IV fentanyl immediately before induction has been shown to minimize incidence of skeletal muscle movements.1 2 10 11

Interactions for Etomidate

Specific Drugs




Neuromuscular blocking agents

Etomidate does not alter usual dosage requirements of neuromuscular blocking agents1 2

Opiate agonists (e.g., fentanyl)

Potential additive pharmacologic effect10

Dosage adjustments (e.g., decreased dosage of etomidate) may be required1 2

Etomidate Pharmacokinetics



Following IV administration, rapid onset of action;1 2 3 4 5 6 loss of consciousness usually occurs within 1 minute.1 2 4 9


Dose dependent.1 2 Following IV administration of average doses (0.3 mg/kg), duration of hypnosis is short (about 3–10 minutes).1 2 765 768

Plasma Concentrations

Minimal hypnotic plasma concentrations are at least 0.23 mcg/mL.1 2



Rapidly distributed from blood into CNS with substantial tissue uptake.3 4

Plasma Protein Binding

Approximately 75%.765



Rapidly metabolized in the liver, principally by hydrolysis, to etomidate carboxylic acid,1 2 3 4 8 which appears to be pharmacologically inactive.4

Elimination Route

Excreted in urine (75%) within 24 hours, mainly (about 80%) as the carboxylic acid metabolite;1 2 4 13 and 10% of a dose are excreted in feces and bile, respectively.4


About 1.25–5 hours.1 2 3 4 8

Special Populations

Elimination half-life approximately doubled in patients with cirrhosis and esophageal varices.1 2





20–25°C.1 2

Do not use the injection unless the solution is clear and the container undamaged.1 2

Discard unused portion.1 2


For information on systemic interactions resulting from concomitant use, see Interactions.


Drug Compatibility
Y-Site CompatibilityHID


Alfentanil HCl

Atracurium besylate

Atropine sulfate

Dexmedetomidine HCl

Ephedrine sulfate

Fentanyl citrate

Lidocaine HCl


Midazolam HCl

Morphine sulfate

Pancuronium bromide

Phenylephrine HCl

Succinylcholine chloride

Sufentanil citrate


Ascorbic acid

Vecuronium bromide


  • Structurally unrelated to other currently available IV anesthetics.6

  • Enhances activity of GABA, the principal inhibitory neurotransmitter in the CNS,6 7 through modulation and direct activation of the GABAA receptor complex.6 7 765

  • Capable of producing all levels of CNS depression—from light sleep to deep coma—depending on the dosage.9

  • Has no analgesic activity.1 2 4

  • Substantial changes on the EEG appear to occur following induction doses.3 4 9 The EEG changes are indicative of the various stages of anesthesia and appear to be similar to those occurring following induction of anesthesia with barbiturates.3 4

  • May decrease cerebral blood flow and intracranial pressure while cerebral perfusion pressure is increased or maintained during induction of anesthesia.1 3 9 765

  • Causes minimal hemodynamic changes9 and is associated with a decreased incidence and severity of cardiovascular effects compared with other IV anesthetic agents.3 4 5 6 10

  • Minor increases in cardiac index and slight decreases in heart rate, systemic vascular resistance, and arterial BP reported.9

  • Equivalent induction doses of etomidate cause less respiratory depression than propofol or barbiturates.9

  • Increases in carbon dioxide tension (PCO2) reported.1 2

  • Usually reduces intraocular pressure (IOP).1 2

Advice to Patients

  • When procedures requiring general anesthetics or sedation drugs, including etomidate, are considered for young children or pregnant women, importance of discussing with the patient, parent, or caregiver the benefits, risks (including potential risk of adverse neurodevelopmental effects), and appropriate timing and duration of the procedure.750 753

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.1 2

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1

  • Importance of informing patients of other important precautionary information.1 (See Cautions.)


Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name



Dosage Forms


Brand Names



Injection, for IV use

2 mg/mL (20 and 40 mg)*



Etomidate Injection

AHFS DI Essentials™. © Copyright 2020, Selected Revisions October 21, 2019. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.


1. West-ward Pharmaceuticals. Etomidate injection prescribing information. Eatontown, NJ; 2018 Apr.

2. Hospira. Amidate (etomidate) injection prescribing information. Lake Forest, IL; 2018 Oct.

3. Batjer HH. Cerebral protective effects of etomidate: experimental and clinical aspects. Cerebrovasc Brain Metab Rev. 1993; 5:17-32.

4. Giese JL Stanley TH. Etomidate: a new intravenous anesthetic induction agent. Pharmacotherapy. 1983; 3:251-8.

5. Preziosi P, Vacca M. Adrenocortical suppression and other endocrine effects of etomidate: minireview. Life Sci. 1988; 42:477- 89.

6. Carmichael FJ, Haas DA. General Anesthetics. In: Kalant H and Roschlau WH, eds. Principles of Medical Pharmacology. 6th edition. New York: Oxford University Press; 1998:278-92.

7. Hales TG, Olsen RW. Basic pharmacology of intravenous induction agents. In: Bowdle TA, Horita A, Kharasch ED. The pharmacologic basis of anesthesiology. New York: Churchill Livingstone; 1994:295-306.

8. Henthorn TK. Pharmacokinetics of intravenous induction agents. In: Bowdle TA, Horita A, Kharasch ED. The pharmacologic basis of anesthesiology. New York: Churchill Livingstone; 1994:307-9.

9. Fragen RJ. Clinical pharmacology and applications of intravenous anesthetic induction agents. In: Bowdle TA, Horita A, Kharasch ED. The pharmacologic basis of anesthesiology. New York: Churchill Livingstone; 1994:319-36.

10. Abbott Laboratories, North Chicago, IL: Personal communication.

11. Stockham RJ, Stanley TH, Pace NL et al. Fentanyl pretreatment modifies anaesthetic induction with etomidate. Anaesth Intensive Care. 1988; 16:171-6.

12. Hampton JP. Rapid-sequence intubation and the role of the emergency department pharmacist. Am J Health Syst Pharm. 2011; 68:1320-30.

13. Flerlage J, Engorn B, eds. The Harriet Lane handbook: a manual for pediatric house officers. 20th ed. Philadelphia, PA: Saunders; 2015:6.

750. US Food and Drug Administration. Drug safety communication: FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women. Silver Spring, MD; 2016 Dec 14. From FDA website.

751. Davidson AJ, Disma N, de Graaff JC et al. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet. 2016; 387:239-50.

752. Sun LS, Li G, Miller TL et al. Association Between a Single General Anesthesia Exposure Before Age 36 Months and Neurocognitive Outcomes in Later Childhood. JAMA. 2016; 315:2312-20.

753. US Food and Drug Administration. Drug safety communication: FDA approves labeling changes for use of general anesthetic and sedation drugs in young children. Silver Spring, MD; 2017 Apr 27. From FDA website.

754. Upchurch CP, Grijalva CG, Russ S et al. Comparison of Etomidate and Ketamine for Induction During Rapid Sequence Intubation of Adult Trauma Patients. Ann Emerg Med. 2017; 69:24-33.e2.

755. Jabre P, Combes X, Lapostolle F et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009; 374:293-300.

756. Mandt MJ, Roback MG, Bajaj L et al. Etomidate for short pediatric procedures in the emergency department. Pediatr Emerg Care. 2012; 28:898-904.

757. Sacchetti A, Stander E, Ferguson N et al. Pediatric Procedural Sedation in the Community Emergency Department: results from the ProSCED registry. Pediatr Emerg Care. 2007; 23:218-22.

758. Di Liddo L, D'Angelo A, Nguyen B et al. Etomidate versus midazolam for procedural sedation in pediatric outpatients: a randomized controlled trial. Ann Emerg Med. 2006; 48:433-40, 440.e1.

759. Disel NR, Yilmaz HL, Sertdemir Y et al. Etomidate Versus Ketamine: Effective Use in Emergency Procedural Sedation for Pediatric Orthopedic Injuries. Pediatr Emerg Care. 2016; 32:830-834.

760. Miner JR, Danahy M, Moch A et al. Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department. Ann Emerg Med. 2007; 49:15-22.

761. Falk J, Zed PJ. Etomidate for procedural sedation in the emergency department. Ann Pharmacother. 2004 Jul-Aug; 38:1272-7.

762. Hunt GS, Spencer MT, Hays DP. Etomidate and midazolam for procedural sedation: prospective, randomized trial. Am J Emerg Med. 2005; 23:299-303.

763. Burton JH, Bock AJ, Strout TD et al. Etomidate and midazolam for reduction of anterior shoulder dislocation: a randomized, controlled trial. Ann Emerg Med. 2002; 40:496-504.

764. American Society of Anesthesiologists. Policy on rapid sequence intubation. Originally approved September 1996 and re-affirmed February 2018, April 2012, October 2006, October 2000. From the ASA website.

765. Forman SA. Clinical and molecular pharmacology of etomidate. Anesthesiology. 2011; 114:695-707.

766. Flynn G, Shehabi Y. Pro/con debate: Is etomidate safe in hemodynamically unstable critically ill patients?. Crit Care. 2012; 16:227.

767. Mayglothling J, Duane TM, Gibbs M et al. Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012; 73(5 Suppl 4):S333-40.

768. Bruder EA, Ball IM, Ridi S et al. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients. Cochrane Database Syst Rev. 2015; 1:CD010225.

769. Cuthbertson BH, Sprung CL, Annane D et al. The effects of etomidate on adrenal responsiveness and mortality in patients with septic shock. Intensive Care Med. 2009; 35:1868-76.

770. Coté CJ, Wilson S, AMERICAN ACADEMY OF PEDIATRICS et al. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics. 2016; 138

771. American College of Emergency Physicians. Policy statement on procedural sedation in the emergency department. Approved June 2017. From the ASA website.

772. Guldner G, Schultz J, Sexton P et al. Etomidate for rapid-sequence intubation in young children: hemodynamic effects and adverse events. Acad Emerg Med. 2003; 10:134-9.

773. Zuckerbraun NS, Pitetti RD, Herr SM et al. Use of etomidate as an induction agent for rapid sequence intubation in a pediatric emergency department. Acad Emerg Med. 2006; 13:602-9.

774. Erdoes G, Basciani RM, Eberle B. Etomidate--a review of robust evidence for its use in various clinical scenarios. Acta Anaesthesiol Scand. 2014; 58:380-9.

821. Godwin SA, Caro DA, Wolf SJ et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2005; 45:177-96.

822. Godwin SA, Burton JH, Gerardo CJ et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014; 63:247-58.e18.

823. . Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology. 2018; 128:437-479.

HID. ASHP’s interactive handbook on injectable drugs. Snow EK, ed. Bethesda, MD: American Society of Health-System Pharmacists, Inc; Updated June 18, 2019. From HID website.

a. AHFS drug information 2020. Snow EK, ed. Etomidate. Bethesda, MD: American Society of Hospital Pharmacists; 2020.