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Ketamine, Etomidate, and Mortality in Emergency Department Intubations.

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Area of Science:

  • Critical Care Medicine
  • Emergency Medicine
  • Pharmacology

Background:

  • The selection of induction agents for rapid sequence intubation (RSI) in critically ill adults can impact patient outcomes.
  • Ketamine and etomidate are commonly used for RSI, but their comparative safety and efficacy remain debated.

Purpose of the Study:

  • To compare the safety and effectiveness of etomidate versus ketamine as induction agents during emergency RSI in critically ill adult patients.
  • To evaluate the association between etomidate or ketamine administration and 28-day in-hospital mortality.

Main Methods:

  • A target trial emulation using observational data from 18 Brazilian emergency departments (March 2022-April 2024).
  • Included adults undergoing RSI with etomidate or ketamine as the sole hypnotic agent, excluding those with preintubation cardiac arrest or immediate post-transfer.
  • Inverse probability of treatment weighting (IPTW) was used to adjust for confounding variables.

Main Results:

  • The study included 1810 patients; 514 received ketamine and 1296 received etomidate.
  • Etomidate use was associated with significantly higher 28-day in-hospital mortality (60.5%) compared to ketamine (54.4%).
  • Higher 7-day mortality was also observed with etomidate (35.2%) versus ketamine (30.1%), and ketamine was linked to more frequent new hemodynamic instability post-intubation.

Conclusions:

  • In this cohort, etomidate administration during emergency RSI in critically ill adults was associated with increased in-hospital mortality at both 7 and 28 days compared to ketamine.
  • The findings underscore the need for rigorous randomized clinical trials to definitively compare the safety profiles of etomidate and ketamine for RSI in this patient population.