(737) Use and Safety of Etomidate for Intubation of Critically Ill Children

Introduction: Etomidate is commonly regarded as a safe medication for tracheal intubation (TI) in children. Recently, etomidate safety has been challenged in adults. This study aimed to better characterize the use of etomidate for TI in critically ill children and assess its safety.

Methods: We evaluated the association between induction agents and safety outcomes in a prospectively collected QI database (National Emergency Airway Registry for Children: NEAR4KIDS) from 2013-2022. Evaluated outcomes included severe hemodynamic TI-associated events (TIAEs) (cardiac arrest, hypotension requiring intervention, and arrhythmia), severe hypoxia (SpO2 decline >20%), and first-attempt success in children receiving etomidate vs. other induction agents. Multivariable logistic regression models assessed the independent associations between etomidate and these outcomes while adjusting for location, patient age/category, shock, difficult airway, apneic oxygenation, device, and neuromuscular blockade use.

Results: A total of 35,401 TIs [etomidate 1,055 (3.0%), other agents 34,346 (97.0%)] were included. Etomidate was more commonly used in the ED compared to the PICU and CICU (26.4% vs. 2.1% and 2.0% of TIs, respectively) and in older children [5.7% (8-17y) vs. 3.0% (1-7 y) vs. 1.6% (0-1y)], both p< 0.001. Etomidate was used in 13.9% of TIs performed for trauma, 5.2% for neurological impairment, 2.8% for shock, 2.8% for cardiac failure, and 1.3% for respiratory failure. In children receiving etomidate, the most common TI indications were neurological (31.9%) and respiratory (19.3%) failures. Etomidate was associated with less hypoxia in univariate (2.2% vs. 3.1%, p< 0.001) and multivariable analysis (OR 0.80, 95% CI: 0.66-0.97, p=0.02). Etomidate was not associated with more severe hemodynamic TIAEs in univariable (2.8% vs. 3.0%, p=0.66) and multivariable analysis (OR 0.93, 95% CI: 0.7-1.3, p=0.64). Finally, etomidate was associated with higher first-attempt success in univariable (75.7% vs. 71.4%, p=0.002) and multivariable analysis (OR 1.18, 95% CI 1.02, 1.37, p=0.03).

Conclusions: Children receiving etomidate experienced less hypoxia but did not have fewer severe hemodynamic TIAEs than those receiving other agents. Etomidate appears to be a safe induction agent in children.