Indian Journal of Critical Care Medicine

Register      Login

SEARCH WITHIN CONTENT

FIND ARTICLE

Volume / Issue

Online First

Archive
Related articles

VOLUME 26 , ISSUE 1 ( January, 2022 ) > List of Articles

SYSTEMATIC REVIEW

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

Saurabh C Sharda, Mandip S Bhatia

Citation Information : 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.

DOI: 10.5005/jp-journals-10071-24086

License: CC BY-NC 4.0

Published Online: 17-01-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Abstract

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 ClinicalTrials.gov 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; I2 = 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; I2 = 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.


HTML PDF Share
  1. Higgins JP, Savovic J, Page MJ, Sterne JA. Revised Cochrane risk-of-bias tool for randomized trials (RoB 2). 2019. Available from: https://www.riskofbias.info/welcome/rob-2-0-tool/current-version-of-rob-2.
  2. OCEBM Levels of Evidence Working Group. The Oxford levels of evidence 2. Oxford Centre for Evidence-Based Medicine. Available from: https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence.
  3. Mudri M, Williams A, Priestap F, Davidson J, Merritt N. Comparison of drugs used for intubation of pediatric trauma patients. J Pediatr Surg 2020;55(5):926–929. DOI: 10.1016/j.jpedsurg.2020.01.041.
  4. Groth CM, Acquisto NM, Khadem T. Current practices and safety of medication use during rapid sequence intubation. J Crit Care 2018;45:65–70. DOI: 10.1016/j.jcrc.2018.01.017.
  5. Upchurch CP, Grijalva CG, Russ S, Collins SP, Semler MW, Rice TW, et al. Comparison of etomidate and ketamine for induction during rapid sequence intubation of adult trauma patients. Ann Emerg Med 2017;69(1):24–33.e2. DOI: 10.1016/j.annemergmed.2016.08.009.
  6. Jabre P, Combes X, Lapostolle F, Dhaouadi M, Ricard-Hibon A, Vivien B, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet 2009;374(9686):293–300. DOI: 10.1016/S0140-6736(09)60949-1.
  7. Van Berkel MA, Exline MC, Cape KM, Ryder LP, Phillips G, Ali NA, et al. Increased incidence of clinical hypotension with etomidate compared to ketamine for intubation in septic patients: a propensity matched analysis. J Crit Care 2017;38:209–214. DOI: 10.1016/j.jcrc.2016.11.009.
  8. Mohr NM, Pape SG, Runde D, Kaji AH, Walls RM, Brown CA. Etomidate use is associated with less hypotension than ketamine for emergency department sepsis intubations: a NEAR cohort study. Acad Emerg Med 2020;27(11):1140–1149. DOI: 10.1111/acem.14070.
  9. April MD, Arana A, Schauer SG, Davis WT, Oliver JJ, Fantegrossi A, et al. Ketamine versus etomidate and peri-intubation hypotension: a national emergency airway registry study. Acad Emerg Med 2020;27(11):1106–1115. DOI: 10.1111/acem.14063.
  10. Driver BE. Ketamine versus etomidate for rapid sequence intubation. ClinicalTrials.gov. 2019. Available from: https://clinicaltrials.gov/ct2/show/study/NCT01823328.
  11. Nakajima S, Taylor K, Zimmerman LH, Collopy K, Fales C, Powers W. Hemodynamic effects of ketamine versus etomidate during rapid sequence intubation in an ED. Crit Care Med 2019;47(1):403. DOI: 10.1097/01.ccm.0000551597.61873.24.
  12. Pollack MA, Fenati GM, Pennington TW, Olvera DJ, Wolfe A, Owens M, et al. The use of ketamine for air medical rapid sequence intubation was not associated with a decrease in hypotension or cardiopulmonary arrest. Air Med J 2020;39(2):111–115. DOI: 10.1016/j.amj.2019.11.003.
  13. Price B, Arthur AO, Brunko M, Frantz P, Dickson JO, Judge T, et al. Hemodynamic consequences of ketamine vs etomidate for endotracheal intubation in the air medical setting. Am J Emerg Med 2013;31(7):1124–1132. DOI: 10.1016/j.ajem.2013.03.041.
  14. Stanke L, Nakajima S, Zimmerman LH, Collopy K, Fales C, Powers W. Hemodynamic effects of ketamine versus etomidate for prehospital rapid sequence intubation. Crit Care Med 2018;46(1):475–475. DOI: 10.1097/01.ccm.0000528991.40952.53.
  15. Farrell NM, Killius K, Kue R, Langlois BK, Nelson KP, Golenia P. A comparison of etomidate, ketamine, and methohexital in emergency department rapid sequence intubation. J Emerg Med 2020;59(4): 508–514. DOI: 10.1016/j.jemermed.2020.06.054.
  16. Patanwala AE, McKinney CB, Erstad BL, Sakles JC. Retrospective analysis of etomidate versus ketamine for first-pass intubation success in an academic emergency department. Acad Emerg Med 2014;21(1):87–91. DOI: 10.1111/acem.12292.
  17. Sivilotti MLA, Filbin MR, Murray HE, Slasor P, Walls RM, NEAR Investigators. Does the sedative agent facilitate emergency rapid sequence intubation? Acad Emerg Med 2003;10(6):612–620. DOI: 10.1111/j.1553-2712.2003.tb00044.x.
  18. Avery P, Morton S, Raitt J, Lossius HM, Lockey D. Rapid sequence induction: where did the consensus go? Scand J Trauma Resusc Emerg Med 2021;29(1):64. DOI: 10.1186/s13049-021-00883-5.
  19. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth 2018;120(2):323–352. DOI: 10.1016/j.bja.2017.10.021.
  20. Granholm A, Alhazzani W, Møller MH. Use of the GRADE approach in systematic reviews and guidelines. Br J Anaesth 2019;123(5):554–559. DOI: 10.1016/j.bja.2019.08.015.
  21. Pagel PS, Kampine JP, Schmeling WT, Warltier DC. Ketamine depresses myocardial contractility as evaluated by the preload recruitable stroke work relationship in chronically instrumented dogs with autonomic nervous system blockade. Anesthesiology 1992;76(4):564–572. DOI: 10.1097/00000542-199204000-00013.
  22. Miller M, Kruit N, Heldreich C, Ware S, Habig K, Reid C, et al. Hemodynamic response after rapid sequence induction with ketamine in out-of-hospital patients at risk of shock as defined by the shock index. Ann Emerg Med 2016;68(2):181–188.e2. DOI: 10.1016/j.annemergmed.2016.03.041.
  23. Patanwala AE, Stahle SA, Sakles JC, Erstad BL. Comparison of succinylcholine and rocuronium for first-attempt intubation success in the emergency department. Acad Emerg Med 2011;18(1):10–14. DOI: 10.1111/j.1553-2712.2010.00954.x.
  24. Fuchs-Buder T, Sparr HJ, Ziegenfuss T. Thiopental or etomidate for rapid sequence induction with rocuronium. Br J Anaesth 1998;80(4):504–506. DOI: 10.1093/bja/80.4.504.
  25. Gill RS, Scott RP. Etomidate shortens the onset time of neuromuscular block. Br J Anaesth 1992;69(5):444–446. DOI: 10.1093/bja/69.5.444.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.