Ketamine and midazolam differently impact post-intubation hemodynamic profile when used as induction agents during emergency airway management in hemodynamically stable patients with ST elevation myocardial infarction

Zuin, Marco; Rigatelli, Gianluca; Dell’Avvocata, Fabio; Faggian, Giuseppe; Conte, Luca; Giatti, Sara; Michielan, F.

doi:10.1007/s00380-017-1049-5

Cited by 12 publications

(6 citation statements)

References 23 publications

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“…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. 13 The objective of this study was to assess the haemodynamic stability of two different induction agents for post-cardiac arrest medical patients requiring PHEA.…”

Section: Original Researchmentioning

confidence: 87%

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

et al. 2021

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BackgroundHypotension following intubation and return of spontaneous circulation (ROSC) after cardiac arrest is associated with poorer patient outcomes. In patients with a sustained ROSC requiring emergency anaesthesia, there is limited evidence to guide anaesthetic practice. At the Essex & Herts Air Ambulance Trust, a UK-based helicopter emergency medical service, we assessed the relative haemodynamic stability of two different induction agents for post-cardiac arrest medical patients requiring prehospital emergency anaesthesia (PHEA).MethodsWe performed a retrospective database review over a 5-year period between December 2014 and December 2019 comparing ketamine-based and midazolam-based anaesthesia in this patient cohort. Our primary outcome was clinically significant hypotension within 30 min of PHEA, defined as a new systolic BP less than 90 mm Hg, or a 10% drop if less than 90 mm Hg before induction.ResultsOne hundred ninety-eight patients met inclusion criteria. Forty-eight patients received a ketamine-based induction, median dose (IQR) 1.00 (1.00–1.55) mg/kg, and a 150 midazolam-based regime, median dose 0.03 (0.02–0.04) mg/kg. Hypotension occurred in 54.2% of the ketamine group and 50.7% of the midazolam group (p=0.673). Mean maximal HRs within 30 min of PHEA were 119 beats/min and 122 beats/min, respectively (p=0.523). A shock index greater than 1.0 beats/min/mm Hg and age greater than 70 years were both associated with post-PHEA hypotension with ORs 1.96 (CI 1.02 to 3.71) and 1.99 (CI 1.01 to 3.90), respectively. Adverse event rates did not significantly differ between groups.ConclusionPHEA following a medical cardiac arrest is associated with potentially significant cardiovascular derangements when measured up to 30 min after induction of anaesthesia. There was no demonstrable difference in post-induction hypotension between ketamine-based and midazolam-based PHEA. Choice of induction agent alone is insufficient to mitigate haemodynamic disturbance, and alternative strategies should be used to address this.

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Section: Original Researchmentioning

confidence: 87%

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

et al. 2021

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“…As a weak sympathomimetic, ketamine is more likely to maintain tissue perfusion during and after RSI, compared to fentanyl, midazolam, thiopental, and especially propofol 29,31–33. In patients with a high shock index, ketamine has been demonstrated to maintain blood pressure34 and is associated with post-intubation hypotension less frequently than other induction agents 35,36. However, ketamine, like any sedative, can cause or worsen hypotension in catecholamine-depleted patients in shock 37.…”

Section: Discussionmentioning

confidence: 99%

Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine

Merelman

Perlmutter

Strayer

2019

WestJEM

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Endotracheal intubation (ETI) is a high-risk procedure commonly performed in emergency medicine, critical care, and the prehospital setting. Traditional rapid sequence intubation (RSI), the simultaneous administration of an induction agent and muscle relaxant, is more likely to harm patients who do not allow appropriate preparation and preoxygenation, have concerning airway anatomy, or severe hypoxia, acidemia, or hypotension. Ketamine, a dissociative anesthetic, can be used to facilitate two alternatives to RSI to augment airway safety in these scenarios: delayed sequence intubation – the use of ketamine to allow airway preparation and preoxygenation in the agitated patient; and ketamine-only breathing intubation, in which ketamine is used without a paralytic to facilitate ETI as the patient continues to breathe spontaneously. Ketamine may also provide hemodynamic benefits during standard RSI and is a valuable agent for post-intubation analgesia and sedation. When RSI is not an optimal airway management strategy, ketamine’s unique pharmacology can be harnessed to facilitate alternative approaches that may increase patient safety.

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“…Based on previous studies, we estimated the incidence of hypotension during induction with remimazolam tosilate, etomidate, and midazolam as 16.7% [ 12 ], 13.3% [ 22 ], and 44.4% [ 16 ], respectively. We hypothesized that remimazolam tosilate was superior to midazolam with superiority marginal = 10% and non-inferior to etomidate with non-inferiority marginal = 10%.…”

Section: Methodsmentioning

confidence: 99%

“…Midazolam is one of the most frequently used sedatives in cardiac anesthesia. However, midazolam has been reported to be associated with a high incidence of hypotension in patients with cardiac disease and undergoing colonoscopy [ 16 , 17 ]. Etomidate is another alternative sedative for patients with cardiovascular diseases due to its remarkably stable cardiorespiratory profile [ 18 , 19 ].…”

Section: Introductionmentioning

confidence: 99%

Efficacy and safety of remimazolam for non-obese patients during anesthetic induction in cardiac surgery: study protocol for a multicenter randomized trial

et al. 2022

Trials

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Background Valvular heart disease remains common in both developed and developing countries, and it requires timely surgical treatment when necessary. However, the stability of hemodynamics during anesthesia induction in patients undergoing valve replacement surgery is difficult to maintain due to their impaired cardiac function. Remimazolam, a novel and ultrashort-acting intravenous sedative-hypnotic, may be beneficial to stable hemodynamics, but the evidence is limited. Therefore, this study aims to evaluate the effect of remimazolam induction on hemodynamics compared with midazolam and etomidate in patients undergoing valve replacement surgery. Methods This is a prospective, multicenter randomized controlled trial (RCT). Three hundred and sixty-three non-obese adult patients aged 45 to 80 years old undergoing valve surgery with cardiopulmonary bypass will be randomly allocated to receive remimazolam tosilate, midazolam, or etomidate during anesthetic induction. The primary outcome is the incidence of hypotension within 20 min after the administration of investigated drugs. The hypotension is defined as systolic blood pressure (SBP) < 90 mmHg or a 30% reduction in SBP from baseline or the application of vasoactive drugs. Secondary outcomes include incidence of successful sedation, time to successful sedation, incidence of delirium and postoperative low cardiac output syndrome within 7 days after surgery, hospital mortality, mechanical ventilation time, ICU length of stay, and hospital length of stay. Discussion To our knowledge, this is the first prospective RCT to investigate the efficacy and safety of remimazolam induction in adult cardiac surgery compared with midazolam and etomidate. This study will provide important information on the application of remimazolam in cardiac surgery in the future. Trial registration Chinese Clinical Trial Registry chictr.org.cn ChiCTR2100050122. Registered on August 16, 2021.

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Ketamine and midazolam differently impact post-intubation hemodynamic profile when used as induction agents during emergency airway management in hemodynamically stable patients with ST elevation myocardial infarction

Cited by 12 publications

References 23 publications

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

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

Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine

Efficacy and safety of remimazolam for non-obese patients during anesthetic induction in cardiac surgery: study protocol for a multicenter randomized trial

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