Ketamine, Etomidate, and Mortality in Emergency Department Intubations

1. Etomidate is associated with significantly higher in-hospital 7- and 28-day mortality compared with ketamine in rapid sequence intubation (RSI) of severely ill patients in the emergency department (ED).

Evidence Rating Level: 2 (Good)

RSI is critical in emergency airway management in critically ill patients. Etomidate and ketamine are favoured induction agents. However, etomidate inhibits adrenal corticosteroid synthesis, while ketamine is associated with peri-intubation hypotension. Recent studies have suggested etomidate may be associated with higher mortality. This target trial emulation of a prospective, multicenter cohort included 1810 patients (median [IQR] age, 64 (50-74) years; 57.9% male)  critically ill patients undergoing emergency intubation across 18 Brazilian EDs. 1048 patients (median [IQR] age, 63 (50-73) years; 59.6% male) received etomidate, and 514 patients (median [IQR] age, 64 (50-74) years; 53.3% male) received ketamine. 7-day (RR, 1.19 [95% CI, 1.04-1.35]; P = .009) and 28-day mortality (RR, 1.14 [95% CI, 1.03-1.27]; P = .01) were significantly higher in the etomidate group. There was no significant difference in the probability of first-attempt intubation success (RR, 0.97 [95% CI, 0.92-1.03]; P = .32). Major adverse events (new hemodynamic instability, severe hypoxemia, cardiac arrest) within 30 minutes after intubation occurred in 31.8% (95% CI, 29.3%-34.3%) of patients in the etomidate group and 30.8% (95% CI, 26.5%-35.2%) of patients in the ketamine group. New hemodynamic instability was less frequent in the etomidate group (RR, 0.78 [95% CI, 0.64-0.95]; P = .02). There were no significant differences in the other complications. While etomidate was associated with a lower risk of peri-intubation hemodynamic instability, it significantly increased mortality at 7 and 28 days. Future randomized clinical trials are required to compare the two agents.

Click here to read this study in JAMA Network Open

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