Ketamine versus propofol for rapid sequence induction in trauma patients: a retrospective study

Abstract

Background Rapid Sequence Induction (RSI) is used for emergency tracheal intubation to minimise the risk of pulmonary aspiration of stomach contents. Ketamine and propofol are two commonly used induction agents for RSI in trauma patients. Yet, no consensus exists on the optimal induction agent for RSI in the trauma population. The aim of this study was to compare 30-day mortality in trauma patients after emergency intubation prehospitally or within 30 min after arrival in the trauma centre using either ketamine or propofol for RSI. Methods In this investigator-initiated, retrospective study we included adult trauma patients emergently intubated with ketamine or propofol registered in the local trauma registry at Rigshospitalet, a tertiary university hospital that hosts a level-1 trauma centre. The primary outcome was 30-day mortality. Secondary outcomes included hospital and Intensive Care Unit length of stay as well as duration of mechanical ventilation. We analysed outcomes using multivariable logistic regression models adjusting for age, sex, injury severity score, shock (systolic blood pressure < 90 mmHg) and Glasgow Coma Scale score before intubation and present results as odds ratios (ORs) with 95% confidence intervals. Results From January 1st, 2015 through December 31st, 2019 we identified a total of 548 eligible patients. A total of 228 and 320 patients received ketamine and propofol, respectively. The 30-day mortality for patients receiving ketamine and propofol was 20.2% and 22.8% (P = 0.46), respectively. Adjusted OR for 30-day mortality was 0.98 [0.58–1.66], P = 0.93. We found no significant association between type of induction agent and hospital length of stay, Intensive Care Unit length of stay or duration of mechanical ventilation. Conclusions In this study, trauma patients intubated with ketamine did not have a lower 30-day mortality as compared with propofol.

Ketamine versus Etomidate for Rapid Sequence Intubation in Patients with Trauma: A Retrospective Study in a Level 1 Trauma center in Korea

“…[21] Recently, the use of ketamine has been increasing owing to its safety, hemodynamic pro le, and effectiveness in the prehospital setting and ED. [13] In this context, we found that patients in the ketamine group tended to have higher GCS and lower head AIS than those in the etomidate group, and they also showed more hemodynamically unstable features.…”

“…[4] A study by Breindahl et al reported no signi cant differences in mortality between ketamine and propofol groups. [13] We performed PSM to overcome potential selection bias and adjust for potential confounding factors. In this study, among patients with trauma intubated using the RSI technique, we found no differences in mortality, ICU LOS, and ventilator days between the ketamine and etomidate groups before and after PSM.…”

“…[8][9][10][11] Ketamine is not associated with adrenal suppression and is known to stimulate the sympathetic nervous system and catecholamine release, which could increase the heart rate and blood pressure by exerting bene cial effects in hemodynamically unstable trauma patients. [12,13] Therefore, ketamine could be used as an alternative to etomidate, with the bene ts of hemodynamic stability and adrenal function. In contrast, catecholamine release can cause myocardial depression and is related to cardiac arrest during emergency endotracheal intubation.…”

Perspective: the top 11 priorities to improve trauma outcomes, from system to patient level

“…Consequently, prioritising succinylcholine [18,19] over non-depolarising muscle relaxants unless contraindicated, removing the cervical collar (if one was applied) and providing manual in-line cervical stabilisation while attempting intubation, routinely using high-flow nasal oxygen and video laryngoscopy during intubation, and quickly excluding a pneumothorax after intubation using ultrasound are all useful recommendations. The greater haemodynamic stability and absence of adrenal suppression associated with ketamine have led many to advocate for its use in trauma rapid sequence induction in preference to propofol or etomidate, although superiority in blood pressure effects [20] or 30-day mortality [21] have not been demonstrated in large observational trauma studies.…”

Abordagem Inicial do Paciente Traumatizado

“…Apesar de sua crescente indicação, estudos comparativos e revisões sistemáticas recentes não mostraram benefícios da Cetamina na redução do tempo de internação e mortalidade em doentes traumatizados, quando comparada a grupos induzidos por outros medicamentos, por exemplo, Etomidato e Propofol. (22)(23)(24) Por fim, a escolha do bloqueador neuromuscular também é importante. Uma revisão sistemática incluiu 50 estudos, representando 4.151 participantes e encontrando evidências de que a succinilcolina cria melhores condições de intubação em comparação com rocurônio, sem efeitos colaterais.…”