Etomidate is the induction agent of choice for haemodynamically unstable patients. Its disadvantage for repeated dosing or prolonged infusion is:

• A Malignant hyperthermia triggering potential
• B Prolonged hypnosis due to cumulative accumulation
• C Adrenocortical suppression lasting 6–12 hours after a single dose, due to inhibition of 11-beta-hydroxylase ✓
• D Severe anaphylaxis more common than with propofol

Explanation

Etomidate inhibits 11-beta-hydroxylase (the enzyme converting 11-deoxycortisol to cortisol) in the adrenal cortex. Even a single induction dose (0.3 mg/kg) suppresses cortisol synthesis for 6–12 hours; this is generally well tolerated in healthy patients but can be harmful in septic shock or adrenal insufficiency. This is why etomidate is no longer recommended as a single-agent induction drug in septic shock patients and is contraindicated for prolonged sedation infusions. Despite excellent haemodynamic stability, pain on injection, myoclonus, and adrenocortical suppression are its principal adverse effects.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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