The Use of Ketamine for Air Medical Rapid Sequence Intubation Was Not Associated With a Decrease in Hypotension or Cardiopulmonary Arrest

Pollack, Melanie A.; Fenati, Gregory; Pennington, Troy; Olvera, David; Wolfe, Allen; Owens, Michelle; Davis, Daniel P.

doi:10.1016/j.amj.2019.11.003

Cited by 11 publications

(13 citation statements)

References 20 publications

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“…Our study is not the first to find that ketamine induction could cause decreases in blood pressure. This analysis found lower blood pressures with ketamine use as well as a higher incidence of post‐RSI hypotension after the ketamine induction, similar to other observational studies 3,4,6,7 . There are mechanisms through which ketamine could cause decrease in blood pressure that might not be present to the same extent in other induction agents.…”

Section: Discussionsupporting

confidence: 87%

“…For example, ketamine is a rapid‐onset anesthetic drug that is thought to maintain favorable cardiopulmonary function, avoids raising intracranial pressure, and does not suppress the adrenal axis 1‐3 . However, some observational studies of ketamine in RSI show that ketamine might be associated with peri‐intubation hypotension, cardiac arrest, and increased requirement for vasopressor use, 3‐6 especially in patients with depleted catecholamine reserves 7 . In contrast, some retrospective studies found less hypotension with ketamine use 8,9 .…”

Section: Introductionmentioning

confidence: 99%

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The association of ketamine induction with blood pressure changes in paramedic rapid sequence intubation of out‐of‐hospital traumatic brain injury

Fouche

Meadley

Clair

et al. 2021

Academic Emergency Medicine

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Introduction Rapid sequence intubation (RSI) is used to secure the airway of traumatic brain injury (TBI) patients, with ketamine frequently used for induction. Studies show that ketamine‐induction RSI might cause lower blood pressures when compared to etomidate. It is not clear if the results from that research can be extrapolated to systems that use different dosing regimens for ketamine RSI. Ambulance Victoria authorized the use of 1.5 mg/kg ketamine in January 2015 for head injury RSI induction by road‐based paramedics. This study aims to examine whether systolic blood pressure changed when ketamine was introduced for prehospital head injury RSI. Methods This study was a retrospective analysis of out‐of‐hospital suspected TBI that received RSI by paramedics. Our analysis employs an interrupted time‐series analysis (ITSA), which is a quasi‐experimental method that tested whether hypotension and systolic blood pressures changed after the switch to ketamine induction in 2015. This ITSA utilized an ordinary least squares regression on complete observations using Newey–West standard errors. Results During the study period, paramedics performed RSI in 8,613 patients, and 1,759 (20.4%) had a TBI. Ketamine usage increased by 52.7% in January 2015 (p < 0.001) after road‐based paramedics were authorized to use ketamine induction. This analysis found significant 5% increase in post‐RSI hypotension (p = 0.046) after the introduction of ketamine, and thereafter the incidence of post‐RSI hypotension increased steadily by 0.5% every 3 months (p = 0.004). Concurrently, changes in systolic blood pressure, as measured by the interval just before induction to the last measured on scene, show an average decrease of 7.8 mm Hg (p = 0.04) at the start of 2015 with the ketamine rollout. Conclusions This ITSA shows that postinduction hypotension and also decreases in systolic blood pressures became evident after the introduction of ketamine. Further research to investigate the association between ketamine induction and survival is needed.

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Section: Discussionsupporting

confidence: 87%

Section: Introductionmentioning

confidence: 99%

The association of ketamine induction with blood pressure changes in paramedic rapid sequence intubation of out‐of‐hospital traumatic brain injury

Fouche

Meadley

Clair

et al. 2021

Academic Emergency Medicine

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“…2 ). 9 , 10 , 12 , 13 , 15 – 17 Meta-analysis of outcomes of these seven studies showed no difference in first-pass intubation success during RSI using etomidate vs ketamine as the induction agent (OR: 1.13; 95% CI: 0.95–1.36; p = 0.17), without significant heterogeneity ( I 2 = 16%; p = 0.31). A graphical summary of the risk of bias evaluations is provided in Figure 3 .…”

Section: R Esultsmentioning

confidence: 97%

Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis

Sharda¹,

Bhatia²

2022

Indian Journal of Critical Care Medicine

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A bstract Aims and objectives The objective of the study was to compare the safety and efficacy of etomidate and ketamine as induction agents for rapid sequence intubation (RSI) in acutely ill patients in emergency department and prehospital settings with respect to post-induction hypotension and first-pass intubation success during RSI. Materials and methods For this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane, and between database inception and June 1, 2021. Articles were included if they compared safety and efficacy of etomidate vs ketamine as induction agents, in patients undergoing RSI in emergency department and prehospital settings, without any restrictions on study design. The outcome measures were incidence of post-induction hypotension and first-pass intubation success. The dichotomous outcomes were assessed for odds ratio (OR) with 95% confidence interval (CI) using random-effects meta-analysis. Results Of 87 records identified, 9 were eligible, all assessed as having a low to moderate risk of overall bias. Six studies, including 12,060 patients from prehospital emergency medical services, air medical transport, and emergency department settings, compared post-induction hypotension incidence between etomidate and ketamine groups. The meta-analysis showed that etomidate was associated with decreased risk of post-induction hypotension compared to ketamine (OR: 0.53; 95% CI: 0.31–0.91; I 2 = 68%). Seven studies, including 15,574 patients, reported on the rate of first-pass intubation success with etomidate vs ketamine. In the pooled analysis, no differences were seen in first-pass intubation success during RSI using etomidate vs ketamine as the induction agent (OR: 1.13; 95% CI: 0.95–1.36; I 2 = 16%). Conclusion The use of etomidate for induction during RSI is associated with a decreased risk of post-induction hypotension as compared to the use of ketamine, without an impact on the first-pass intubation success rate. How to cite this article Sharda SC, Bhatia MS. Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022;26(1):108–113.

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“…The switch from the physiological baseline of negative pressure ventilation to positive pressure causes an increase in intrathoracic pressure and therefore decreases both cardiac output and venous return. 2 Peri-intubation hypotension may also be attributed to the sympatholytic effect of RSI medications. Critically ill patients may be dependent upon the effects of endogenous catecholamines to maintain hemodynamic stability.…”

mentioning

confidence: 99%

The Effect of Full-Dose Versus Half-Dose Ketamine for Induction During Rapid Sequence Intubation on Patient Outcomes

Asberry,

Martini

2024

Critical Care Nursing Quarterly

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Prehospital rapid sequence intubation (RSI), like inpatient RSI, is not without risk of adverse effects to the patient. The most notable of these adverse effects is postintubation hemodynamic instability. Air medical providers choose induction agents for critically ill patients who require emergent airway management, some of whom may already be hemodynamically unstable prior to RSI. Ketamine is often selected as the induction agent of choice for patients who are either unstable before RSI or have a high index of suspicion of becoming unstable in the postintubation period. Although widely considered to have a good safety profile for induction, ketamine administration has been correlated with episodes of postintubation hypotension. In this retrospective literature review, the effect of using half-dose ketamine for induction in patients who show pre-RSI instability (systolic blood pressure <90 mm Hg or body mass index >30) on postintubation hemodynamics is examined.

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The Use of Ketamine for Air Medical Rapid Sequence Intubation Was Not Associated With a Decrease in Hypotension or Cardiopulmonary Arrest

Cited by 11 publications

References 20 publications

The association of ketamine induction with blood pressure changes in paramedic rapid sequence intubation of out‐of‐hospital traumatic brain injury

The association of ketamine induction with blood pressure changes in paramedic rapid sequence intubation of out‐of‐hospital traumatic brain injury

Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis

The Effect of Full-Dose Versus Half-Dose Ketamine for Induction During Rapid Sequence Intubation on Patient Outcomes

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