Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis

Abstract

A bstract Aims and objectives The objective of the study was to compare the safety and efficacy of etomidate and ketamine as induction agents for rapid sequence intubation (RSI) in acutely ill patients in emergency department and prehospital settings with respect to post-induction hypotension and first-pass intubation success during RSI. Materials and methods For this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane, and between database inception and June 1, 2021. Articles were included if they compared safety and efficacy of etomidate vs ketamine as induction agents, in patients undergoing RSI in emergency department and prehospital settings, without any restrictions on study design. The outcome measures were incidence of post-induction hypotension and first-pass intubation success. The dichotomous outcomes were assessed for odds ratio (OR) with 95% confidence interval (CI) using random-effects meta-analysis. Results Of 87 records identified, 9 were eligible, all assessed as having a low to moderate risk of overall bias. Six studies, including 12,060 patients from prehospital emergency medical services, air medical transport, and emergency department settings, compared post-induction hypotension incidence between etomidate and ketamine groups. The meta-analysis showed that etomidate was associated with decreased risk of post-induction hypotension compared to ketamine (OR: 0.53; 95% CI: 0.31–0.91; I 2 = 68%). Seven studies, including 15,574 patients, reported on the rate of first-pass intubation success with etomidate vs ketamine. In the pooled analysis, no differences were seen in first-pass intubation success during RSI using etomidate vs ketamine as the induction agent (OR: 1.13; 95% CI: 0.95–1.36; I 2 = 16%). Conclusion The use of etomidate for induction during RSI is associated with a decreased risk of post-induction hypotension as compared to the use of ketamine, without an impact on the first-pass intubation success rate. How to cite this article Sharda SC, Bhatia MS. Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022;26(1):108–113.

Life-threatening pulmonary embolism: overview and management

“…In one study, propofol was found to independently increase mortality rates compared to midazolam as a procedural sedative in massive PE 37 . In the setting of rapid sequence intubation, ketamine and etomidate are both well-studied agents that may be chosen for their minimal hemodynamic effect, though recent literature has documented increased rates of hypotension with ketamine in patients who are already hemodynamically compromised before intubation, which is believed to be due to ketamine-induced exhaustion of catecholamine reserves 38,39 . For continuous sedation on mechanical ventilation, a benzodiazepine infusion again carries a milder risk profile in regards to heart rate and blood pressure but is associated with other complications such as prolonged time on the ventilator and delirium.…”

“…37 In the setting of rapid sequence intubation, ketamine and etomidate are both well-studied agents that may be chosen for their minimal hemodynamic effect, though recent literature has documented increased rates of hypotension with ketamine in patients who are already hemodynamically compromised before intubation, which is believed to be due to ketamine-induced exhaustion of catecholamine reserves. 38,39 For continuous sedation on mechanical ventilation, a benzodiazepine infusion again carries a milder risk profile in regards to heart rate and blood pressure but is associated with other complications such as prolonged time on the ventilator and delirium. Dexmedetomidine, a selective α2 agonist, is associated with shorter times to extubation and decreased rates of delirium when compared with benzodiazepine; however, it also carries the potential to cause profound hypotension and bradycardia through its anti-adrenergic effects.…”

Utilização Do Etomidato Como Substância De Indução Na Intubação Orotraqueal De Pacientes Graves

“…Nesse contexto, tem-se o etomidato, um hipnótico não barbitúrico de ação ultrarrápida e administração intravenosa utilizado para a indução na IOT (Williams;Boyd;Fitzgerald, 2023). O etomidato está associado à diminuição do risco de hipotensão pós-indução durante a intubação de sequência rápida (Sharda;Bhatia, 2022), mas ainda é importante compreender as nuances da aplicação deste fármaco em pacientes complicados.…”

Comparison of the hemodynamic effects of etomidate-midazolam and ketamine-midazolam combinations in anesthesia induction in coronary artery bypass surgery

“…Different anesthesia induction protocols are administered for this purpose. Etomidate and ketamine are potentially more suitable agents in terms of preventing hypotension, one of the problems that arise during anesthesia induction [3].…”