Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial

Matchett, Gerald; Gasanova, Irina; Riccio, Christina A.; Nasir, Dawood; Sunna, Mary; Bravenec, Brian J; Azizad, Omaira; Farrell, Brian; Minhajuddin, Abu; Stewart, Jesse W; Liang, Lawrence W; Moon, Tiffany S.; Fox, Pamela E.; Ebeling, Callie; Smith, Miakka N; Trousdale, Devin; Ogunnaike, Babatunde; Abraham, Anand M.; Ackerman, Robert S.; Adebayo-Adonis, Oluwafunmilayo B.; Aiyagari, Venkatesh; Ambardekar, Aditee; Anyaehie, Kelechi B.; Bashover, David M.; Bourneuf, Matthew Burke; Brann, James R.; Bryant, Grace Wilkowski; Bunker, Matthew P.; Catoe, Leigh Anne; Chen, Catherine; Chen, Jeffrey S.; Chen, Joy Lo; Cheng, Gloria; Chew, Ivan Nicholas; Chin, Jeanette L.; Cohen, Samuel M.; Cowlishaw, Mary Abigail; Davis, Janice; Davis, Jennifer L.; Davis, TomMario; DePinto, David G.; Dilfer, Paul E.; Doherty, Renee D.; DuChamp, Philip James; Duncan, Katherine L.; Ehlenbach, Colin C.; Elsharydah, Ahmad; Estes, Sonia D.; Farishta, Akil; Foster, William Eric; Francis, David G.; Garitty, Shannon; Gill, Nicholas W.; Gliga, Louise A.; Graham, Joseph Arthur; Greilich, Nancy B.; Grundt, Jessica E.; Hamilton, Allan J.; Heravi, Hooman; Huynh, Douglas C.; Hwong, Ray K.; Jacobs, Rachel E.; Jaffery, Syed; Jerome, Aveline P.; John, Suja; Kandil, Enas; Khan, Asif; Khorsand, Sarah; Kim, Jennifer Meeyun; Koepke, Elena; Koval, Grayson Jeffrey; Kurtz, Brian P.; Langridge, Xuan T.; Lee, Gene W.; Lee, Simon J. Craddock; Leveno, Matthew; Lewellen, Dawn; Li, Frederick C.; Loo, Nathaniel; Luo, Xi; Makinde, Rachelle A.; Martin, Anna; Mayes, Evan Z.; McCune, Diane E.; McGrimley, John; McGuire, Jennifer J.; Meinhardt, Kyle; Merchant, Akeel; Merchant, Zahid; Mercier, David; Mitchell, Brandon C.; Murray, Andrea J.; Musa, Shamsideen O.; Nelson, Geoffrey Edward; Nelson, Seth; Nguyen, Ly Sy Phu; Nohrn, Linsey; Obanor, Osamudiamen O.; Ononogbu, Chinwe C.; Parikh, Mihir

doi:10.1007/s00134-021-06577-x

Cited by 63 publications

(28 citation statements)

References 39 publications

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“…Although ketamine was the first-line recommendation for hemodynamic instability patients during intubation due to its superior hemodynamic effect [ 30 ], a recent prospective randomized single-center study reported that for emergency EI, etomidate was comparable to ketamine in the 28 mortality rate. Nevertheless, propofol and midazolam were the most frequently prescribed as induction agents [ 31 , 32 ], and our investigation revealed a similar outcome, with lower rates of ketamine and etomidate use. This may be attributable to the fact that ketamine is currently unavailable in China, as well as concerns regarding etomidate's adrenal suppression in sepsis patients.…”

Section: Discussionsupporting

confidence: 59%

Airway Management in Adult Intensive Care Units: A Survey of Two Regions in China

Zhang

Lin

Diao

et al. 2022

BioMed Research International

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The critical medicine residency training in China started in 2020, but no investigation on the practice of tracheal intubation in ICUs in China has been conducted. A survey was sent to the adult ICUs in public hospitals in Shenzhen (SZ) city and Xinjiang (XJ) province using a WeChat miniprogram to be completed by intensive care physicians. It included questions on training on intubation, intubation procedures, and changes in the use of personal protective equipment due to COVID-19. We analyzed 301 valid questionnaires which were from 72 hospitals. A total of 37% of respondents had completed training in RSI (SZ, 40% vs. XJ, 30%; p = 0.066 ), and 50% had participated in a course on the emergency front of the neck airway (SZ, 47% vs. XJ, 54%; p = 0.256 ). Video laryngoscopy was preferred by 75% of respondents. Manual ventilation (56%) and noninvasive positive pressure ventilation (34%) were the first-line options for preoxygenation. For patients with a high risk of aspiration, nasogastric decompression (47%) and cricoid pressure (37%) were administered. Propofol (82%) and midazolam (70%) were the most commonly used induction agents. Only 19% of respondents routinely used neuromuscular blocking agents. For patients with difficult airways, a flexible endoscope was the most commonly used device by 76% of respondents. Most participants (77%) believed that the COVID-19 pandemic had significantly increased their awareness of the need for personal protective equipment during tracheal intubation. Our survey demonstrated that the ICU doctors in these areas lack adequate training in airway management.

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Section: Discussionsupporting

confidence: 59%

Airway Management in Adult Intensive Care Units: A Survey of Two Regions in China

Zhang

Lin

Diao

et al. 2022

BioMed Research International

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“…Etomidate is commonly used for induction of anesthesia in patients with hemodynamic instability owing to its low risk of hypotension. 19 , 20 However, adrenocortical function inhibition is one of the most important adverse effects of etomidate, which limits its clinical application to some extent. 19 , 21 , 22…”

Section: Discussionmentioning

confidence: 99%

Comparison of Remimazolam Tosilate and Etomidate on Hemodynamics in Cardiac Surgery: A Randomised Controlled Trial

Hu¹,

Zhang²,

Zhang³

et al. 2023

DDDT

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Background Remimazolam tosilate (RT) is a new ultrashort-acting γ-aminobutyric acid subtype A (GABA A ) agonist, with the characteristics of rapid onset and offset, minimal cardiorespiratory depression. Currently, few studies have compared the effect of RT and etomidate on hemodynamics during anesthesia induction. Here, we aimed to compare the hemodynamic effects of different doses of RT and etomidate for anesthesia induction in patients undergoing cardiac surgeries. Methods Patients were recruited from January to September 2022 in this single-center, prospective, randomized, double-blind trial. A total of 117 patients undergoing selective valve replacement surgery were randomly divided into low-dose RT (0.2 mg/kg) group (group LR), high-dose RT (0.3 mg/kg) group (group HR), or etomidate (1.5 mg/kg) group (group E), respectively. The primary outcome was hemodynamic fluctuations (mean arterial pressure fluctuation value [∆MAP]; heart rate fluctuation value [∆HR]) during anesthesia induction. Secondary outcomes included the incidence of adverse drug reactions (injection pain and myoclonus) and adverse cardiovascular events, vital signs at different time points and the cumulative doses of vasoactive drugs. Results The hemodynamic fluctuations (∆MAP) in group LR and group E were significantly lower than that in group HR. In addition, the incidence of hypotension and the cumulative norepinephrine doses in group E and group LR were also significantly lower than that in group HR. Furthermore, the incidence of injection pain and myoclonus in group LR and group HR were less frequently recorded compared with group E. There were no significant differences in terms of ∆HR, tachycardia, hypertension, severe bradycardia, vital signs at different time points, lactic acid and blood glucose between both groups. Conclusion Compared with etomidate, low-dose RT (0.2mg/kg) can not only provide stable hemodynamic parameters but also cause fewer adverse reactions when used for anesthesia induction in patients with cardiac disease.

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“…In addition, the identification of patients at high risk for PIHI may be helpful for the choice of the induction drug. Based on a recent randomized trial showing that ketamine use is associated with reduced cardiovascular collapse after intubation and improved day-7 survival when compared to etomidate, ketamine should be recommended in patients at high risk for PIHI [ 34 ]…”

Section: Discussionmentioning

confidence: 99%

Peripheral tissue hypoperfusion predicts post intubation hemodynamic instability

Dubée

Hariri

Joffre

et al. 2022

Ann. Intensive Care

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Background Tracheal intubation and invasive mechanical ventilation initiation is a procedure at high risk for arterial hypotension in intensive care unit. However, little is known about the relationship between pre-existing peripheral microvascular alteration and post-intubation hemodynamic instability (PIHI). Methods Prospective observational monocenter study conducted in an 18-bed medical ICU. Consecutive patients requiring tracheal intubation were eligible for the study. Global hemodynamic parameters (blood pressure, heart rate, cardiac function) and tissue perfusion parameters (arterial lactate, mottling score, capillary refill time [CRT], toe-to-room gradient temperature) were recorded before, 5 min and 2 h after tracheal intubation (TI). Post intubation hemodynamic instability (PIHI) was defined as any hemodynamic event requiring therapeutic intervention. Results During 1 year, 120 patients were included, mainly male (59%) with a median age of 68 [57–77]. The median SOFA score and SAPS II were 6 [4–9] and 47 [37–63], respectively. The main indications for tracheal intubation were hypoxemia (51%), hypercapnia (13%), and coma (29%). In addition, 48% of patients had sepsis and 16% septic shock. Fifty-one (42%) patients develop PIHI. Univariate analysis identified several baseline factors associated with PIHI, including norepinephrine prior to TI, sepsis, tachycardia, fever, higher SOFA and high SAPSII score, mottling score ≥ 3, high lactate level and prolonged knee CRT. By contrast, mean arterial pressure, baseline cardiac index, and ejection fraction were not different between PIHI and No-PIHI groups. After adjustment on potential confounders, the mottling score was associated with a higher risk for PIHI (adjusted OR: 1.84 [1.21–2.82] per 1 point increased; p = 0.005). Among both global haemodynamics and tissue perfusion parameters, baseline mottling score was the best predictor of PIHI (AUC: 0.72 (CI 95% [0.62–0.81]). Conclusions In non-selected critically ill patients requiring invasive mechanical ventilation, tissue hypoperfusion parameters, especially the mottling score, could be helpful to predict PIHI.

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Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial

Cited by 63 publications

References 39 publications

Airway Management in Adult Intensive Care Units: A Survey of Two Regions in China

Airway Management in Adult Intensive Care Units: A Survey of Two Regions in China

Comparison of Remimazolam Tosilate and Etomidate on Hemodynamics in Cardiac Surgery: A Randomised Controlled Trial

Peripheral tissue hypoperfusion predicts post intubation hemodynamic instability

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