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Abstract

Learning Objectives: Etomidate is commonly used for intubation with minimal hemodynamic effects, however its suppression of cortisol production may have a significant impact on a patient's ability to maintain hemodynamic stability. Ketamine is also frequently used and has minimal effects on hemodynamics but no proven influence on the adrenal axis. Methods: A retrospective cohort study was performed to compare the incidence of clinical hypotension between ketamine and etomidate in critically ill septic patients. Clinical hypotension was defined as: mean arterial pressure (MAP) decrease > 40% and MAP <70 mmHg, MAP <60 mmHg, systolic blood pressure (SBP) 15 min, initiation of vasopressors, or increase to > 30% of the initial vasopressor dose. In addition, patients were evaluated for length of hospital and ICU stay, and mortality. Statistical analyses included unmatched and matched cohorts using a propensity score analysis. Multivariable logistic regression was used to evaluate the incidence of clinical hypotension 24 hr post intubation and vasopressor requirements. Results: A total of 260 patients were included for analysis (129 etomidate and 131 ketamine) with 138 patients matched 1:1 based on propensity score. Prior to propensity matching, clinical hypotension 24 hr post intubation was 75.2% in the etomidate group compared to 69.5% in the ketamine group (p=0.302) and there was no statistical difference in new post intubation shock (37.2%; 48.5%, p=0.067). After matching no statistical difference was found in clinical hypotension within 24 hr (40.6%; 40.6%, p=0.99). A random-effects logistic regression model was applied and there was a 38% reduction in clinical hypotension with ketamine (OR=0.62; 95% CI 0.3-1.29, p=0.2). There was also no statistical difference in ICU or hospital length of stay or mortality. Conclusions: Administration of etomidate for intubation did not increase the incidence of clinical hypotension 24 hr post intubation when compared to ketamine in septic patients. Large, prospective trials are warranted to confirm these results.