Ketamine, Etomidate, and Mortality in Emergency Department Intubations.
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Maia Ian Ward A, Decker Sérgio R R, Oliveira J E Silva Lucas, von Hellmann Rafael, Alencar Julio C G, Hajjar Ludhmila Abrahao, de Carvalho Julia M Dorn, Pedrollo Daniel F, Nogueira Caio G, Figueiredo Natalia Mansur P, Miranda Carlos Henrique, Martins Danilo, Baumgratz Thiago D, Bergesch Bruno, Colleoni Osmar, Zanettini Juliana, Freitas Ana Paula, Tambelli Renato, Costa Maria Cristina, Correia Wilsterman, de Maria Rafael G, Filho Ubirajara A V, Weber Andre P, da Silva Castro Vinicius, Dornelles Carlos Fernando D, Tabach Barbara S, Moreira Nicole P, Gaspar Patricia L, Guimarães Hélio P, Stanzani Gabriela, Gava Thiago F, Mullan Aidan, Brown Caitlin S, Bellolio Fernanda, Jeffery Molly M, Ranzani Otavio T, Besen Bruno A M P, Brazilian Airway Registry Cooperation (BARCO) group
Аннотация
OBJECTIVE: To compare the safety of etomidate vs ketamine for emergency RSI in critically ill adults.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used a target trial emulation with observational data collected between March 1, 2022, and April 30, 2024, from 18 emergency departments across Brazil, with data from the Brazilian Airway Registry Cooperation. Adults who underwent RSI and received either etomidate or ketamine as a sole hypnotic agent were included; those with preintubation cardiac arrest or immediate postintubation transfer were excluded.
EXPOSURE: Administration of etomidate or ketamine as the induction agent for RSI.
MAIN OUTCOMES AND MEASURES: The primary outcome was 28-day in-hospital mortality. Secondary outcomes included 7-day in-hospital mortality, first-attempt intubation success, and major adverse events (new hemodynamic instability, severe hypoxemia, and cardiac arrest) within 30 minutes after intubation. Inverse probability of treatment weighting was used to adjust for confounding. Risk ratios (RRs) and risk differences (RDs) with 95% CIs were used to compare outcomes between groups.
RESULTS: Among 1810 patients (median age, 64 years [IQR, 50-74 years]; 1048 men [57.9%]), 514 received ketamine and 1296 received etomidate. The median shock index was higher in the ketamine group than the etomidate group (0.81 [IQR, 0.65-1.01] vs 0.76 [IQR, 0.59-0.99]), and preintubation vasopressor use was more common in the ketamine group than the etomidate group (191 of 514 [37.2%] vs 391 of 1296 [30.2%]). Weighted 28-day mortality was higher with etomidate than ketamine (60.5% [95% CI, 57.2%-63.8%] vs 54.4% [95% CI, 45.0%-63.9%]; RR, 1.14 [95% CI, 1.03-1.27]; RD, 7.6% [95% CI, 2.0%-13.3%]). Seven-day mortality was also higher with etomidate than ketamine (35.2% [95% CI, 32.0%-38.3%] vs 30.1% [95% CI, 23.5%-36.7%]; RR, 1.19 [95% CI, 1.04-1.35]). New hemodynamic instability within 30 minutes after intubation was more frequent with ketamine (24.2% [95% CI, 20.4%-28.0%] vs 18.9% [95% CI, 16.7%-21.0%]; RR, 0.78 [0.64-0.95]). There were no statistically significant differences in the other secondary outcomes.
CONCLUSIONS AND RELEVANCE: In this cohort study of critically ill adults undergoing RSI, etomidate use was associated with higher in-hospital mortality at 7 and 28 days compared with ketamine. These findings highlight the need for definitive randomized clinical trials to compare both agents.