Etomidate Versus Midazolam for Procedural Sedation in Pediatric Outpatients: A Randomized Controlled Trial

Study objective

Midazolam is widely used for procedural sedation and analgesia. Etomidate has been studied mostly in adults. Our objective is to compare the efficacy of etomidate and midazolam for achieving procedural sedation and analgesia in children.

Methods

A randomized, double-blind, emergency department and orthopedic clinic-based trial was carried out among patients aged 2 to 18 years with displaced extremity fractures. Patients were administered 1 μg/kg of fentanyl and either 0.2 mg/kg of etomidate or 0.1 mg/kg of midazolam. Adequate sedation was defined, for the purpose of this study, as a score of 4 or more on the Ramsay Sedation Scale. The primary outcome was induction and recovery time. The rates of adverse events, success of fracture reduction, and parent and physician satisfaction were also compared.

Results

From April to August 2004, 100 of 128 eligible patients were enrolled (age 8.7±3.7 years; 50% male patients). A higher proportion of patients attained adequate sedation among those who received etomidate: 46 of 50 (92%) versus 18 of 50 (36%) (Δ 56%; 95% confidence interval [CI] 38% to 69%). Time taken for induction (hazard ratio 4.9; 95% CI 2.2 to 10.9) and time taken for recovery (hazard ratio 2.8; 95% CI 1.5 to 5.1) were lower among patients who received etomidate. The rates of adverse events were similar in both groups, except for myoclonus and pain at the injection site, which was more frequent in the etomidate group.

Conclusion

Induction and recovery times are shorter with etomidate compared with midazolam. At the dosages used for procedural sedation and analgesia among children with displaced extremity fracture, etomidate has higher efficacy in comparison with midazolam.

Introduction

Painful procedures in the pediatric emergency department (ED) are frequent and the underuse of analgesia and sedation among children has been well documented.¹ The ideal sedative agent for procedural sedation and analgesia would have a rapid onset of action and a brief half-life, therefore permitting easy titration on response and a rapid recovery time once the procedure is over. Also, it would induce amnesia and sedation and decrease muscular tone while having no adverse effects. Unfortunately, no single agent has all these properties. Midazolam, a benzodiazepine, is the most widely used intravenous sedative in the ED for adults, as well as children.2, 3, 4, 5 Although well accepted for procedural sedation and analgesia, its time of onset is relatively long, and the recovery time can be prolonged with high doses.3, 6 It also has the potential for inducing respiratory depression and hypotension.⁷ A drug that offers promise for procedural sedation and analgesia is etomidate. Its use has been initially described for rapid sequence intubation in the ED in adults, as well as in children.8, 9, 10 It offers a rapid onset of sedative effect, brief half-life, short recovery time, and minimal effect on the respiratory and cardiovascular systems.¹¹

Balancing adequate procedural sedation and analgesia with rapid discharge after the procedure is a major challenge to emergency physicians. The use of etomidate would greatly reduce the time nurses and physicians have to stay at the patient’s bedside, ensuring a faster turnover without compromising patient safety. However, there is a paucity of literature that addresses the use of etomidate for procedural sedation and analgesia specifically in large samples of outpatient children.

The objective of this study was thus to compare the induction and recovery times of etomidate and midazolam in children presenting to the pediatric ED and orthopedics clinic with extremity fractures requiring procedural sedation and analgesia for reduction at a large tertiary-care facility.