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Association Between Receipt of Ketamine vs Etomidate for Emergency Tracheal Intubation and Symptoms of Posttraumatic
Lucas C Wollenman1, Austin M Tipold1, Matthew W Semler1
1Department of Emergency Medicine (L. C. W., A. M. T., W. H. S., S. D., and J. H. H.), the Division of Allergy, Pulmonary, and Critical Care Medicine (M. W. S., J. D. C., A. L. K., P. T. B., J. C. J., and E. W. E.), Department of Medicine, the Vanderbilt Institute for Clinical and Translational Research (M. W. S., J. D. C., and W. H. S.), the Critical Illness, Brain Dysfunction, and Survivorship Center (A. L. K., P. T. B., J. C. J., E. W. E., and J. H. H.), the Department of Biostatistics (C. A. J., and G. W.), Vanderbilt University Medical Center; the Geriatric Research, Education, and Clinical Center (J. C. J., E. W. E., and J. H. H.), Tennessee Valley Healthcare Center, Nashville, TN; the Department of Emergency Medicine (A. J. L.), Washington University, St. Louis, MO; and the Department of Emergency Medicine (I. H. S.), University of Colorado School of Medicine, Aurora, CO.
Background:
One of 3 patients in the ICU receiving mechanical ventilation demonstrates posttraumatic stress disorder (PTSD). A single dose of ketamine has been shown to reduce PTSD symptoms in outpatients with chronic PTSD, but its long-term effect is unknown in patients who are critically ill and mechanically ventilated.
Research Question:
Is ketamine, when used for induction of anesthesia before emergency tracheal intubation, associated with fewer symptoms of PTSD at 12 months compared with etomidate?
Study Design And Methods:
This was a secondary analysis of a cluster-randomized trial that examined the effect of oxygen saturation targets in patients receiving invasive mechanical ventilation in an emergency department or ICU. Symptoms of PTSD were assessed by trained neuropsychologist raters using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (PCL-5) by phone. Scores ranged from 0 to 80, with higher scores indicating more severe PTSD symptoms. A score of ≥ 31 indicated probable PTSD. Symptoms of PTSD were compared between patients who received ketamine and patients who received etomidate using a proportional odds logistic regression model adjusting for age, race, sex, education, depression or PTSD before illness, comorbidities, severity of illness, sepsis, and location of intubation.
Results:
Among the 141 patients included in this analysis, 52 patients (37%) received ketamine and 89 patients (63%) received etomidate. The median PCL-5 score at 12 months was 7 (interquartile range [IQR], 1-18) for patients who received ketamine and 14 (IQR, 5-27) for patients who received etomidate (reference; adjusted OR, 0.39; 95% CI, 0.20-0.76). A total of 8 patients (15.4%) who received ketamine and 18 patients (20.2%) who received etomidate met criteria for probable PTSD.
Conclusions:
Compared with etomidate, induction with ketamine during emergency tracheal intubation was associated with significantly fewer symptoms of PTSD at 12 months. A randomized trial is needed to confirm this finding.
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