Efficacy and Safety of Etomidate Versus Ketamine for Endotracheal Intubation in Critically Ill Patients: A Systematic Review and Meta-Analysis.

Rapid sequence intubation (RSI) is a commonly used technique for critically ill patients requiring emergency intubation, and the choice of induction agent is crucial for minimizing peri-intubation morbidity and maintaining hemodynamic stability. The most commonly used induction agents are etomidate and ketamine, although controversy remains about their effectiveness and safety. Therefore, this systematic review and meta-analysis compared the efficacy and safety of etomidate versus ketamine for endotracheal intubation in critically ill patients. Randomized controlled trials (RCTs) published between 2000 and May 2026 were systematically searched in PubMed, The Cochrane Library, and ScienceDirect. The included studies compared etomidate with ketamine for emergency endotracheal intubation in critically ill adults. We analyzed data with RevMan 5.4 and Mantel-Haenszel random-effects models and calculated risk ratios (RRs) with 95% confidence intervals (CIs). Seven RCTs involving 5234 patients were included in the final analysis. No significant difference was observed between etomidate and ketamine regarding 28-day mortality (RR 1.01; 95% confidence interval (CI) 0.93-1.10; p=0.84), cardiac arrest (RR 0.91; 95% CI 0.62-1.34; p = 0.64), failed intubation (RR 1.09; 95% CI 0.68-1.76; p=0.71), or vasopressor requirement (RR 1.27; 95% CI 0.94-1.72; p=0.13). Sensitivity analyses suggested possible hemodynamic differences between the two agents, which should be interpreted cautiously, and etomidate was relatively cardiovascularly stable in some analyses. Overall, etomidate and ketamine showed similar efficacy and safety for endotracheal intubation in critically ill patients. No statistically significant differences were observed between the two agents in mortality, cardiac arrest, failed intubation, or vasopressor use. Thus, clinicians should choose the induction agent on a case-by-case basis, based on patient, hemodynamic, and clinician-specific factors. Randomized trials in selected critically ill patient populations should be conducted on a larger scale.