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Medically reviewed by Last updated on Sep 28, 2020.


(e TOM i date)

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Intravenous:

Amidate: 2 mg/mL (10 mL, 20 mL) [contains propylene glycol]

Generic: 2 mg/mL (10 mL, 20 mL)

Solution, Intravenous [preservative free]:

Generic: 2 mg/mL (10 mL [DSC], 20 mL [DSC])

Brand Names: U.S.

  • Amidate

Pharmacologic Category

  • General Anesthetic


Ultra-short-acting nonbarbiturate general anesthetic (benzylimidazole) used for rapid induction of anesthesia with minimal cardiovascular effects; produces EEG burst suppression at high doses.


Vd: 2 to 4.5 L/kg


Hepatic and plasma esterases


Urine ~ 75% (80% as metabolite; 2% as unchanged drug)

Onset of Action

30 to 60 seconds; Peak effect: 1 minute

Time to Peak

Serum: 7 minutes

Duration of Action

Dose dependent: 2 to 3 minutes (0.15 mg/kg dose); 3 to 5 minutes (0.3 mg/kg dose); rapid recovery is due to rapid redistribution

Half-Life Elimination

Terminal: 2.6 to 3.5 hours

Protein Binding

76%; decreased protein binding resulting in an increased percentage of “free” etomidate in patients with renal failure or hepatic cirrhosis

Special Populations: Hepatic Function Impairment

Vd and elimination half-life increase 2-fold in patients with cirrhosis compared with healthy subjects.

Special Populations: Elderly

Vd, total clearance, and plasma protein binding are decreased in elderly patients.

Use: Labeled Indications

General anesthesia: Induction of general anesthesia; as a supplement to subpotent anesthetic agents during maintenance of anesthesia for short operative procedures (eg, rapid sequence intubation, dilation and curettage, cervical conization).

Off Label Uses

Cushing syndrome

Based on the Endocrine Society’s Clinical Practice Guidelines for Treatment of Cushing’ Syndrome, etomidate, given for severe hypercortisolism in critically ill patients with Cushing syndrome, is an effective and recommended agent in patients who are not immediate surgical candidates and cannot take oral medications. Etomidate is also an effective and recommended treatment for acute unmanageable symptoms associated with severe hypercortisolism (eg, psychosis, respiratory failure) until other medical/surgical therapies for Cushing syndrome can be performed [ES [Nieman 2015]].

Procedural sedation

In a randomized, nonblinded, prospective trial, etomidate, although it appeared equally safe for procedural sedation in the emergency department (ED), had lower procedural success compared to propofol in adults undergoing procedural sedation. Notably, etomidate induced myoclonus in 20% of patients compared to 1.8% of patients receiving propofol [Miner 2007]. A retrospective study for procedural sedation found that the use of etomidate was effective in 93% of subjects in the ED with few adverse events, although many adverse events (eg, myoclonus) may not be well documented in the ED [Vinson 2002].

Based on the American College of Emergency Physicians clinical policy for procedural sedation and analgesia in the ED, etomidate may be safely administered to adults for procedural sedation in the ED [Godwin 2014].


Hypersensitivity to etomidate or any component of the formulation

Dosing: Adult

Cushing syndrome (off-label use): Note: Studies have not reported sedation at these etomidate doses; however, patients should be managed in an intensive care unit with sedation scoring every 2 hours initially for the first 24 hours, then every 12 hours. Cortisol levels should be measured every 4 to 6 hours (ES [Nieman 2015]; Preda 2012). Optimal regimen and doses have not been identified; refer to institutional protocols.

IV: Initial: 3 to 5 mg loading dose, followed by 0.02 to 0.05 mg/kg/hour continuous IV infusion (usually equates to 1.5 to 4 mg/hour). Titrate to serum cortisol of 18 to 29 mcg/dL (500 to 800 nmol/L) in a physiologically stressed patient or 5.5 to 11 mcg/dL (150 to 300 nmol/L) in a nonphysiologically stressed patient. For complete blockade, titrate infusion rate to achieve a cortisol level <5.5 mcg/dL (<150 nmol/L). Hydrocortisone IV is required if complete blockade desired rather than partial blockade (‘block and replace’) (Carroll 2018; ES [Nieman 2015]; Preda 2012).

General anesthesia: IV: Initial: 0.3 mg/kg (range: 0.2 to 0.6 mg/kg) over 30 to 60 seconds for induction of anesthesia.

Procedural sedation (off-label use): IV: Initial: 0.1 to 0.2 mg/kg, followed by 0.05 mg/kg every 3 to 5 minutes as needed (Bahn 2005; Miner 2007; Vinson 2002).

Rapid sequence intubation outside the operating room (induction): Note: Provides no analgesic effects (Stollings 2014).

IV: Initial: 0.3 mg/kg; consider 0.2 mg/kg in hemodynamically unstable patients (Stollings 2014; Upchurch 2017).

Supplementation to subpotent anesthetic agents: IV: Administer smaller increments during short operative procedures to supplement subpotent anesthetic agents, such as nitrous oxide; individualize dosage (usually smaller than the original induction dose).

Dosing: Geriatric

Refer to adult dosing; reduced doses may be required.

Dosing: Pediatric

Anesthesia, induction:

Infants: Very limited data available: IV: 0.2 to 0.3 mg/kg/dose as a single dose; dosing based on a prospective, observational trial and two pharmacokinetic studies (Kay 1976; Lin 2012; Su 2015)

Children <10 years: Limited data available: IV: 0.2 to 0.3 mg/kg/dose as a single dose (Coté 2013; Du 2015; Kay 1976)

Children ≥10 years and Adolescents: Usual dose: IV: 0.3 mg/kg/dose as a single dose; range: 0.2 to 0.6 mg/kg/dose

Procedural sedation: Limited data available; dosing variable: Infants ≥6 months, Children, and Adolescents: IV: Usual initial dose: 0.2 mg/kg/dose prior to procedure (reported range: 0.1 to 0.4 mg/kg/dose); repeat doses may be needed depending on patient response and duration of the procedure; repeat doses vary in the literature and range from 0.1 to 0.2 mg/kg/dose; reported total dose ranged from 0.3 to 0.6 mg/kg/procedure; dosing based on several prospective and retrospective studies primarily in the ED setting; procedures included orthopedic reductions and sedation for CT scans (Baxter 2007; Dickinson 2001; Di Liddo 2006; Lee-Jayaram 2010; Kienstra 2004; Mandt 2012). Note: Etomidate does not have analgesic properties; additional therapy (eg, fentanyl) may be needed for painful procedures (ACEP [Godwin 2014]).

Rapid sequence intubation (RSI): Limited data available: Infants, Children, and Adolescents: IV, Intraosseous: 0.2 to 0.4 mg/kg/dose as a single dose; maximum dose: 20 mg/dose (AHA [Hazinski 2015]; Hegenbarth 2008). Note: Not recommended for patients in septic shock due to an association between transient adrenocortical suppression and increased mortality rate (den Brinker 2008; PALS [Kleinman 2010]).


IV: Administer IV push over 30 to 60 seconds. Solution is highly irritating; avoid administration into small vessels; in some cases, preadministration of lidocaine may be considered.


Store at 20°C to 25°C (68°F to 77°F).

Drug Interactions

Fexinidazole [INT]: May increase the serum concentration of Products Containing Propylene Glycol. Avoid combination

MetroNIDAZOLE (Systemic): May enhance the adverse/toxic effect of Products Containing Propylene Glycol. A disulfiram-like reaction may occur. Avoid combination

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.


Central nervous system: Myoclonus (33%)

Endocrine & metabolic: Adrenal suppression

Gastrointestinal: Nausea, vomiting (on emergence from anesthesia)

Local: Pain at injection site (30% to 80%)

Neuromuscular & skeletal: Musculoskeletal disease (transient skeletal movements)

Ophthalmic: Nystagmus

1% to 10%: Gastrointestinal: Hiccups

<1%, postmarketing, and/or case reports: Apnea, bradycardia, cardiac arrhythmia, decreased cortisol (decreased cortisol synthesis), hypertension, hyperventilation, hypotension, hypoventilation, laryngospasm, muscle spasm (masseter; Bozeman 2002), tachycardia


Concerns related to adverse effects:

• Adrenal steroid production: Etomidate inhibits 11-B-hydroxylase, an enzyme important in adrenal steroid production. A single induction dose blocks the normal stress-induced increase in adrenal cortisol production for 6 to 8 hours, up to 24 hours in elderly and debilitated patients. Continuous infusion of etomidate for sedation in the ICU may increase mortality because patients may not be able to respond to stress. Administration by continuous infusion is not recommended by the manufacturer. No increase in mortality has been identified with a single dose for induction of anesthesia (McPhee 2013).

Disease-related concerns:

• Heart failure: In a scientific statement from the American Heart Association, etomidate has been determined to be an agent that may exacerbate underlying myocardial dysfunction (magnitude: moderate) (AHA [Page 2016]).

• Renal impairment: Risk of toxicity is greater in patients with renal impairment; use with caution and monitor renal function.

Special populations:

• Elderly: May induce cardiac depression in elderly patients, especially those with hypertension; may require lower doses.

• Pediatric neurotoxicity: In pediatric and neonatal patients <3 years and patients in third trimester of pregnancy (ie, times of rapid brain growth and synaptogenesis), the repeated or lengthy exposure to sedatives or anesthetics during surgery/procedures may have detrimental effects on child or fetal brain development and may contribute to various cognitive and behavioral problems. Epidemiological studies in humans have reported various cognitive and behavioral problems, including neurodevelopmental delay (and related diagnoses), learning disabilities, and ADHD. Human clinical data suggest that single, relatively short exposures are not likely to have similar negative effects. No specific anesthetic/sedative has been found to be safer. For elective procedures, risks versus benefits should be evaluated and discussed with parents/caregivers/patients; critical surgeries should not be delayed (FDA 2016).

Other warnings/precautions:

• Appropriate use: When considering use, weigh etomidate hemodynamic properties against the high frequency of transient skeletal muscle movements.

• Experienced personnel: According to the manufacturer, etomidate should only be administered by experienced personnel trained in the administration of general anesthetics and in the management of complications encountered during the conduct of general anesthesia. Consult local regulations and individual institutional policies and procedures.

Monitoring Parameters

Cardiac monitoring; blood pressure; renal function (in renal impairment)

Pregnancy Considerations

Etomidate crosses the placenta (Esener 1992; Gregory 1991).

Based on animal data, repeated or prolonged use of general anesthetic and sedation medications that block N-methyl-D-aspartate receptors and/or potentiate GABA activity may affect brain development. Evaluate benefits and potential risks of fetal exposure to etomidate when duration of surgery is expected to be >3 hours (Olutoye 2018).

Use of etomidate for induction of anesthesia prior to cesarean delivery has been described (Downing 1979; Houlton 1978; Regaert 1984). However, other agents are more commonly used (ACOG 209 2019).

The ACOG recommends that pregnant women should not be denied medically necessary surgery, regardless of trimester. If the procedure is elective, it should be delayed until after delivery (ACOG 775 2019).

Patient Education

What is this drug used for?

• It is used to put you to sleep for surgery.

• It may be given to you for other reasons. Talk with the doctor.

All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away:

• Fatigue

• Nausea

• Vomiting

• Twitching

• Injection site pain

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect:

• Severe dizziness

• Passing out

• Vision changes

• Trouble breathing

• Slow breathing

• Shallow breathing

• Fast heartbeat

• Slow heartbeat

• Abnormal heartbeat

• Involuntary eye movements

• Stiff muscles

• Abnormal movements

• Severe headache

• Injection site irritation

• Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a limited summary of general information about the medicine's uses from the patient education leaflet and is not intended to be comprehensive. This limited summary does NOT include all information available about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not intended to provide medical advice, diagnosis or treatment and does not replace information you receive from the healthcare provider. For a more detailed summary of information about the risks and benefits of using this medicine, please speak with your healthcare provider and review the entire patient education leaflet.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.