The effect between etomidate and ketamine on peri-intubation hypotension in elderly patients in the emergency department

1. There was no significant difference in peri-intubation hypotension (PIH) and 28-day mortality between etomidate and ketamine as a single induction agent in elderly patients.

Evidence Rating Level: 2 (Good)

Peri-intubation hypotension (PIH) is a common complication of tracheal intubation with greater risk in elderly patients given the reductive effects of age-related physiological changes and comorbidities on their cardiovascular reserve. Etomidate and ketamine are preferred agents due to their relatively minimal hemodynamic disturbance although data on their use in elderly agents is limited. This study therefore sought to compare the effects of etomidate and ketamine on PIH and 28-day mortality in elderly patients. This prospective, observational cohort study included418 emergency department patients aged 65 years and older requiring tracheal intubation who received either etomidate or ketamine as a single induction agent. PIH was defined as a decrease in systolic blood pressure (SBP) by more than 20% from baseline without treatment, SBP less than 100 mmHg without treatment, or the initiation of vasopressors. The study found no difference in PIH incidence within 30 minutes of medication administration across the two groups (risk difference 9.1 %, 95 % confidence interval [CI] −4.1 to 22.1, p = 0.179) or in 28-day mortality (hazard ratio [HR] 0.66, 95 % CI 0.41–1.07, p = 0.095). However, ketamine was associated with a lower risk of 28-day mortality (adjusted HR 0.59, 95 % CI 0.36–0.97, p = 0.034) in patients who developed PIH and required vasopressors. Furthermore, in patients with a shock index ≥ 0.9, dosage was positively correlated with the probability of PIH in both groups. This study contributes to the existing literature of induction agent selection in tracheal intubation and may support the use of etomidate in certain sub-populations.

Click here to read this study in The American Journal of Emergency Medicine

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