Association of ketamine use with lower risks of post-intubation hypotension in hemodynamically-unstable patients in the emergency department

Abstract

To determine whether ketamine use for tracheal intubation, compared to other sedative use, is associated with a lower risk of post-intubation hypotension in hemodynamically-unstable patients in the emergency department (ED), we analyzed the data of a prospective, multicenter, observational study—the second Japanese Emergency Airway Network (JEAN-2) Study—from February 2012 through November 2017. The current analysis included adult non-cardiac-arrest ED patients with a pre-intubation shock index of ≥0.9. The primary exposure was ketamine use as a sedative for intubation, with midazolam or propofol use as the reference. The primary outcome was post-intubation hypotension. A total of 977 patients was included in the current analysis. Overall, 24% of patients developed post-intubation hypotension. The ketamine group had a lower risk of post-intubation hypotension compared to the reference group (15% vs 29%, unadjusted odds ratio [OR] 0.45 [95% CI 0.31–0.66] p < 0.001). This association remained significant in the multivariable analysis (adjusted OR 0.43 [95% CI 0.28–0.64] p < 0.001). Likewise, in the propensity-score matching analysis, the patients with ketamine use also had a significantly lower risk of post-intubation hypotension (OR 0.47 [95% CI, 0.31–0.71] P < 0.001). Our observations support ketamine use as a safe sedative agent for intubation in hemodynamically-unstable patients in the ED.

Cardiovascular complications of prehospital emergency anaesthesia in patients with return of spontaneous circulation following medical cardiac arrest: a retrospective comparison of ketamine-based and midazolam-based induction protocols

“…10 A prospective Japanese registry study showed lower rates of hypotension in haemodynamically unstable patients without preceding cardiac arrest when induced with ketamine, compared with either midazolam or propofol. 11 In hospitalised patients with ST-elevation myocardial infarction requiring intubation, midazolam use was again associated with a greater rate of hypotension when compared with ketamine. 12 However, our own service has demonstrated an acceptable cardiovascular profile following PHEA with a standardised fentanyl-midazolam-rocuronium induction.…”

A specialized airway management team for COVID-19 patients: a retrospective study of the experience of two Canadian hospitals in Toronto

“…This may be related to the known myocardial depressant effects of ketamine, or may be due to residual confounding related to ketamine being chosen as an induction agent in sicker patients. 20 , 21 Patient harm can be minimized by anticipating and preparing to manage these adverse effects, as well as having skilled and experienced team members working as a cohesive unit. 22 This is borne out by the absence of periprocedural cardiac arrest in our population, which was associated with prompt administration of supplemental vasopressors in appropriate doses.…”

Propofol, Ketamine, and Etomidate as Induction Agents for Intubation and Outcomes in Critically Ill Patients: A Retrospective Cohort Study

“…In a prospective observational study of patients undergoing rapid sequence intubation with ketamine in the out-of-hospital setting, hypotension was observed in up to 24% in patients with high shock index, whereas patients with low shock index had sustained increase in blood pressure and heart rate ( 22 ). In a prospective multicenter study of intubation in hemodynamically unstable patients, ketamine exposure was associated with 15% postintubation hypotension albeit less than the 25% seen with midazolam-propofol combination ( 23 ). So, the assumption that ketamine is safe to use in hemodynamically unstable patients may be misleading as some patients may experience potentially sustained paradoxical hypotension.…”