Ketamine for emergency endotracheal intubation: insights into post-induction hemodynamic instability. Author’s reply

Matchett, Gerald; Azizad, Omaira; Bravenec, Brian J; Farrell, Brian; Nasir, Dawood

doi:10.1007/s00134-022-06692-3

Cited by 5 publications

(3 citation statements)

References 6 publications

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“…This topic has been investigated in two randomized trials, in which, however, only a minority of participants were trauma patients. Matchett et al 48 observed lower survival at 7 days in the etomidate group but no significant difference by day 28. Likewise, Jabre et al 15 did not observe a difference in mortality risk during the 28-day follow-up period.…”

Section: Discussionmentioning

confidence: 92%

Etomidate versus Ketamine as Prehospital Induction Agent in Patients with Suspected Severe Traumatic Brain Injury

Mansvelder,

Bossers,

Loer

et al. 2024

Anesthesiology

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Introduction Severe traumatic brain injury (TBI) is a leading cause of morbidity and mortality among young people around the world. Prehospital care focusses on the prevention and treatment of secondary brain injury and commonly includes tracheal intubation after induction of general anesthesia. The choice of induction agent in this setting is controversial. We therefore investigated the association between the chosen induction medication etomidate versus S(+)-ketamine , and the 30-day mortality in patients with severe TBI who received prehospital airway management in the Netherlands. Methods We conducted a retrospective analysis of the prospectively collected observational data of the BRAIN-PROTECT cohort study. Patients with suspected severe TBI, who were transported to a participating trauma center and who received etomidate or S(+)-ketamine for prehospital induction of anesthesia for advanced airway management were included. Statistical analyses were performed with multivariable logistic regression and Inverse Probability of Treatment Weighting analysis. Results In total, 1457 patients were eligible for analysis. No significant association between the administered induction medication and 30-day mortality was observed in unadjusted analyses (etomidate 32.9% mortality versus S(+)-ketamine 33.8% mortality, p= 0.716, OR 1.04, 95% CI 0.83 to 1.32, p= 0.711) as well as after adjustment for potential confounders (OR 1.08, 95% CI 0.67 to 1.73, p= 0.765; risk difference 0.017, 95% CI -0.051 to 0.084, p= 0.686). Likewise, in planned subgroup analyses for patients with confirmed TBI and patients with isolated TBI, no significant differences were found. Consistent results were found after multiple imputation of missing data. Conclusions We found no evidence for an association between the use of etomidate or S(+)-ketamine as an anesthetic agent for intubation in patients with TBI and mortality after 30 days in the prehospital setting, suggesting that the choice of induction agent may not influence patient mortality rate in this population.

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Section: Discussionmentioning

confidence: 92%

Etomidate versus Ketamine as Prehospital Induction Agent in Patients with Suspected Severe Traumatic Brain Injury

Mansvelder,

Bossers,

Loer

et al. 2024

Anesthesiology

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“…In addition to administering prophylactic vasopressors, two other interventions have been tested to decrease the risk of per-intubation hypotension: choice of induction agent and administration of an IV fluid bolus. In a recent trial comparing etomidate versus ketamine for induction of emergency intubation, etomidate was associated with a reduced incidence of cardiovascular collapse but had no statistically significant impact on 28-day survival (40). The use of induction agents (etomidate, ketamine, and propofol) was similar between groups in our propensity-matched cohort.…”

Section: Discussionmentioning

confidence: 99%

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials

Fuchita

Pattee

Russell

et al. 2023

Critical Care Explorations

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OBJECTIVE: Hypotension affects approximately 40% of critically ill patients undergoing emergency intubation and is associated with an increased risk of death. The objective of this study was to examine the association between prophylactic vasopressor administration and the incidence of peri-intubation hypotension and other clinical outcomes. DESIGN: A secondary analysis of two multicenter randomized clinical trials. The clinical effect of prophylactic vasopressor administration was estimated using a one-to-one propensity-matched cohort of patients with and without prophylactic vasopressors. SETTING: Seven emergency departments and 17 ICUs across the United States. PATIENTS: One thousand seven hundred ninety-eight critically ill patients who underwent emergency intubation at the study sites between February 1, 2019, and May 24, 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was peri-intubation hypotension defined as a systolic blood pressure less than 90 mm Hg occurring between induction and 2 minutes after tracheal intubation. A total of 187 patients (10%) received prophylactic vasopressors prior to intubation. Compared with patients who did not receive prophylactic vasopressors, those who did were older, had higher Acute Physiology and Chronic Health Evaluation II scores, were more likely to have a diagnosis of sepsis, had lower pre-induction systolic blood pressures, and were more likely to be on continuous vasopressor infusions prior to intubation. In our propensity-matched cohort, prophylactic vasopressor administration was not associated with reduced risk of peri-intubation hypotension (41% vs 32%; p = 0.08) or change in systolic blood pressure from baseline (–12 vs –11 mm Hg; p = 0.66). CONCLUSIONS: The administration of prophylactic vasopressors was not associated with a lower incidence of peri-intubation hypotension in our propensity-matched analysis. To address potential residual confounding, randomized clinical trials should examine the effect of prophylactic vasopressor administration on peri-intubation outcomes.

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“…However, both French and American recommendations do not specify a preferred agent [4,5], suggesting ketamine and etomidate for the hypnotic agent and succinylcholine or rocuronium for the curare. Several recent trials have failed to identify any superiority of one sedative or paralytic agent over the other [6–8].…”

mentioning

confidence: 99%

Sequence of administration of anesthetic agents during rapid sequence induction for emergency intubation: a French survey on current practices

Catoire,

Roussel,

Teissandier

2023

European Journal of Emergency Medicine

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Ketamine for emergency endotracheal intubation: insights into post-induction hemodynamic instability. Author’s reply

Cited by 5 publications

References 6 publications

Etomidate versus Ketamine as Prehospital Induction Agent in Patients with Suspected Severe Traumatic Brain Injury

Etomidate versus Ketamine as Prehospital Induction Agent in Patients with Suspected Severe Traumatic Brain Injury

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials

Sequence of administration of anesthetic agents during rapid sequence induction for emergency intubation: a French survey on current practices

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