Increased incidence of clinical hypotension with etomidate compared to ketamine for intubation in septic patients: A propensity matched analysis

Berkel, Megan A. Van; Exline, Matthew C.; Cape, Kari; Ryder, Lindsay; Phillips, Gary; Ali, Nora’aini; Doepker, Bruce

doi:10.1016/j.jcrc.2016.11.009

Cited by 34 publications

(22 citation statements)

References 29 publications

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“…2,3,[5][6][7][8]10,17 Ketamine's reputed hemodynamic stability has led to recommendations that it might be preferable to etomidate for induction during rapid sequence intubation of sepsis patients. 1,[18][19][20][21][22] Others have questioned whether ketamine is hemodynamically neutral in sepsis patients. 13,23,24 Our study demonstrates that etomidate is used as the induction agent for patients with sepsis in EDs 16% less frequently than for nonsepsis intubations.…”

Section: Discussionmentioning

confidence: 99%

“…Ketamine is an excellent alternative induction agent in sepsis because of its stable hemodynamic profile and its lack of adrenal suppression. 1,9,[18][19][20][21][22] Recent studies, however, have suggested that ketamine may be associated with a significant risk of hypotension, especially in patients with catecholamine depletion. 13,23,24 Randomized and observational studies comparing etomidate versus ketamine have shown mixed results in short-term adverse events such as hypotension.…”

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confidence: 99%

“…13,23,24 Randomized and observational studies comparing etomidate versus ketamine have shown mixed results in short-term adverse events such as hypotension. 21,25 With an estimated 1.7 million sepsis cases in the United States per year, and 26% of those cases requiring endotracheal intubation, optimizing intubation safety is important to improve sepsis outcomes. 26 Prior work has focused on the relationship between induction agent selection and long-term survival, but there has been little focus on how these data have influenced induction agent selection or ED complications from endotracheal intubation in this population.…”

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confidence: 99%

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Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study

Mohr

Pape

Runde

et al. 2020

Academic Emergency Medicine

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Objective: The objectives of this study were 1) to describe the current use of etomidate and other induction agents in patients with sepsis and 2) to compare adverse events between etomidate and ketamine in sepsis. Methods: This was an observational cohort study of the prospective National Emergency Airway Registry (NEAR) data set. Descriptive statistics were used to report the distribution of induction agents used in patients with sepsis. Adverse events were compared using bivariate analysis, and a sensitivity analysis was conducted using a propensity score-adjusted analysis of etomidate versus ketamine. Results: A total of 531 patients were intubated for sepsis, and the majority (71%) were intubated with etomidate as the initial induction agent. Etomidate was less frequently used in sepsis patients than nonsepsis patients (71% vs. 85%, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.4 to 0.5). Sepsis patients had a greater risk of adverse events, and vasopressor therapy was required for 25% of patients after intubation. Postprocedure hypotension was higher between those intubated for sepsis with ketamine versus etomidate (74% vs. 50%, OR = 2.9, 95% CI = 1.9 to 4.5). After confounding by indication in the propensity score-adjusted analysis was accounted for, ketamine was associated with more postprocedure hypotension (OR = 2.7, 95% CI = 1.1 to 6.7). No difference in emergency department deaths was observed. Conclusions: Etomidate is used less frequently in sepsis patients than nonsepsis patients, with ketamine being the most frequently used alternative. Ketamine was associated with more postprocedural hypotension than etomidate. Future clinical trials are needed to determine the optimal induction agent in patients with sepsis. E tomidate is commonly used as an induction agent for rapid sequence induction in critically ill patients in the emergency department (ED) because of its reliable sedation effect and stable hemodynamic profile. 1 Etomidate also inhibits adrenal steroidogenesis by its transient inhibition of 11 b-hydroxylase, 2-4 which has raised safety concerns in patients with sepsis. 3,5-8 Based on cohort studies and post hoc

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study

Mohr

Pape

Runde

et al. 2020

Academic Emergency Medicine

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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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“…Etomidate is regarded as hemodynamically neutral and remains a common and reliable option in unstable patients (8,17,45). Ketamine has been used safely in patients with shock and is regarded as having favorable hemodynamic effects and avoids the controversial risk of reversible adrenal suppression associated with etomidate (25,41,46,47). Ketamine acts as a sympathomimetic by stimulating the release of endogenous catecholamines.…”

Section: Hypotension and Shockmentioning

confidence: 99%

High-Risk Airway Management in the Emergency Department. Part I: Diseases and Approaches

Lentz

Grossman

Koyfman

et al. 2020

The Journal of Emergency Medicine

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Increased incidence of clinical hypotension with etomidate compared to ketamine for intubation in septic patients: A propensity matched analysis

Cited by 34 publications

References 29 publications

Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study

Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study

Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine

High-Risk Airway Management in the Emergency Department. Part I: Diseases and Approaches

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