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Etomidate versus Ketamine as Prehospital Induction Agent in Patients with Suspected Severe Traumatic Brain Injury
Floor J Mansvelder1, Sebastiaan M Bossers1, Stephan A Loer1
1Department of Anesthesiology, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
Insights
For severe traumatic brain injury patients requiring prehospital intubation, neither etomidate nor S(+)-ketamine induction agents were associated with significant differences in 30-day mortality. This finding suggests the choice of anesthetic agent may not impact patient survival rates in this critical setting.
Area of Science:
- Emergency Medicine
- Neuroscience
- Pharmacology
Background:
- Severe traumatic brain injury (TBI) is a major cause of death and disability globally, particularly in young individuals.
- Prehospital care for TBI aims to prevent secondary brain injury, often involving tracheal intubation under general anesthesia.
- The selection of anesthetic induction agents for TBI patients in the prehospital setting remains a subject of debate.
Purpose of the Study:
- To investigate the association between etomidate and S(+)-ketamine as induction agents and 30-day mortality in severe TBI patients.
- To compare the safety and efficacy of etomidate versus S(+)-ketamine for prehospital airway management in TBI patients.
Main Methods:
- Retrospective analysis of prospectively collected data from the BRAIN-PROTECT cohort study.
- Inclusion of patients with suspected severe TBI undergoing prehospital anesthesia induction with etomidate or S(+)-ketamine.
- Statistical analysis using multivariable logistic regression and inverse probability of treatment weighting.
Main Results:
- 1,457 patients were analyzed; no significant association was found between etomidate or S(+)-ketamine and 30-day mortality in unadjusted or adjusted analyses.
- Mortality rates were similar: 32.9% for etomidate vs. 33.8% for S(+)-ketamine (P=0.716 unadjusted; P=0.765 adjusted).
- Subgroup analyses for confirmed and isolated TBI, and analyses with imputed missing data, yielded consistent results.
Conclusions:
- No evidence suggests a link between etomidate or S(+)-ketamine use and 30-day mortality in prehospital TBI patients.
- The choice of induction agent (etomidate vs. S(+)-ketamine) does not appear to influence patient mortality in this population.
- Findings support the use of either agent in prehospital TBI management without a significant impact on survival outcomes.
Background:
Severe traumatic brain injury is a leading cause of morbidity and mortality among young people around the world. Prehospital care focuses on the prevention and treatment of secondary brain injury and commonly includes tracheal intubation after induction of general anesthesia. The choice of induction agent in this setting is controversial. This study therefore investigated the association between the chosen induction medication etomidate versus S(+)-ketamine and the 30-day mortality in patients with severe traumatic brain injury who received prehospital airway management in the Netherlands.
Methods:
This study is a retrospective analysis of the prospectively collected observational data of the Brain Injury: Prehospital Registry of Outcomes, Treatments and Epidemiology of Cerebral Trauma (BRAIN-PROTECT) cohort study. Patients with suspected severe traumatic brain injury who were transported to a participating trauma center and who received etomidate or S(+)-ketamine for prehospital induction of anesthesia for advanced airway management were included. Statistical analyses were performed with multivariable logistic regression and inverse probability of treatment weighting analysis.
Results:
In total, 1,457 patients were eligible for analysis. No significant association between the administered induction medication and 30-day mortality was observed in unadjusted analyses (32.9% mortality for etomidate versus 33.8% mortality for S(+)-ketamine; P = 0.716; odds ratio, 1.04; 95% CI, 0.83 to 1.32; P = 0.711), as well as after adjustment for potential confounders (odds ratio, 1.08; 95% CI, 0.67 to 1.73; P = 0.765; and risk difference 0.017; 95% CI, -0.051 to 0.084; P = 0.686). Likewise, in planned subgroup analyses for patients with confirmed traumatic brain injury and patients with isolated traumatic brain injury, no significant differences were found. Consistent results were found after multiple imputations of missing data.
Conclusions:
The analysis found no evidence for an association between the use of etomidate or S(+)-ketamine as an anesthetic agent for intubation in patients with traumatic brain injury and mortality after 30 days in the prehospital setting, suggesting that the choice of induction agent may not influence the patient mortality rate in this population.
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