The EvK Trial: Ketamine vs Etomidate for Rapid Sequence Intubation

This is an unblinded, single-center trial using an anesthesia team for intubation, with missing data and significant sources of bias. Therefore, we are skeptical of the results, and it is difficult to draw conclusions from the data presented in this paper. The debate concerning which is the superior induction agent for RSI continues.

A review of etomidate for rapid sequence intubation in the emergency department

The pharmacological and safety profiles of etomidate offer many advantages for RSI in the ED. Its onset of action is rapid and predictable, and its duration of action is comparable to commonly used induction agents such as thiopental, ketamine and propofol.

Clinical and Molecular Pharmacology of Etomidate

Among general anesthesia induction drugs, etomidate is the only imidazole, and it has the most favorable therapeutic index for single-bolus administration. It also produces a unique toxicity among anesthetic drugs: inhibition of adrenal steroid synthesis that far outlasts its hypnotic action and that may reduce survival of critically ill patients.

Critical Care Alert: The EvK Clinical Trial: Etomidate vs. Ketamine For Emergency Endotracheal Intubation

In this single-center RCT, critically ill patients who received ketamine for rapid-sequence induction had > 7-day survival over those who received etomidate. The tradeoff was more rescue therapy with vasopressors due to cardiovascular collapse in patients in the ketamine arm so be prepared to have vasopressors ready if electing to use ketamine.

Drugs are Gonna Knock You Out – Etomidate vs. Ketamine...

Both ketamine and etomidate have similar hemodynamic stability, but both should be used with caution in the critically ill patient. There may be certain patient populations who might benefit from one medication over the other, but more research is needed on this topic. Regardless of which agent used there should be a focus on optimizing patient physiology by aggressively resuscitating before you intubate. Considering lower dosing for either induction agent in the critically ill may be further protective.

Etomidate

As a cardiothoracic anesthesiologist and intensivist, one would think etomidate would be my induction drug of choice for hemodynamically labile patients in the OR and ICU; however, these are also the patients who need their endogenous production of steroids! In my opinion, propofol is just a much more predictable medication with more favorable side effect profile. Many equate rapid sequence inductions (RSI) with etomidate + succinylcholine, but for me, it has always been propofol + succinylcholine/rocuronium + hemodynamic meds (calcium, phenylephrine, esmolol, etc).

Etomidate for RSI induction? St Emlyn’s

This was a drug that I became very familiar with as a trainee, but which fell out of favour over concerns about adrenal suppression, and with the wider acceptability of ketamine as an induction agent.

Etomidate for sedating critically ill people during emergency endotracheal intubation

Although we have not found conclusive evidence that etomidate increases mortality or healthcare resource utilization in critically ill patients, it does seem to increase the risk of adrenal gland dysfunction and multi-organ system dysfunction by a small amount. The clinical significance of this finding is unknown.

Etomidate vs. Ketamine in Trauma RSI

This study found no association between induction agent used for RSI (ketamine or etomidate) and in-hospital mortality. A prospective, RDCT should be undertaken to confirm or refute these findings. Based on the best available evidence, it does not appear that induction with either ketamine or etomidate is superior to the other in terms of mortality in trauma patients requiring ED RSI.

Etomidate Vs. Ketamine: A Systematic Review and Meta-Analysis

The data presented adds to the growing body of literature about RSI induction. However, due to the lack of high-quality RCTs and the large impact and weighting of flawed studies included in the meta-analysis, we remain skeptical of the findings…The debate continues.

Etomidate: to use or not to use for endotracheal intubation in the critically ill?

The following editorial discusses current evidence regarding etomidate use for endotracheal intubation and mortality. In particular, we highlight a recent article with the largest population to date that found no association between etomidate and mortality in the critically ill...

Ketamine and Rocuronium: The New Etomidate and Succinylcholine?

Recent studies have shown no difference in usage of ketamine versus etomidate, and rocuronium versus succinylcholine in intubation conditions and first pass success in the Emergency Department. Ketamine is less likely to cause post-intubation hypotension. While etomidate has demonstrated adrenal suppression with just one dose in multiple studies, ketamine has not shown any such complications. An increase in mortality, lower cortisol levels, more ventilator days and longer ICU stays are associated with prolonged IV etomidate usage. No study has demonstrated an increase in mortality with single dose etomidate. However, single dose etomidate has shown maximal adrenal suppression at 4 to 6 hours post administration. Adrenal suppression can result in hypotension, and post-intubation hypotension does correlate with increased in-hospital mortality. With critically ill patients, maintaining their bodies’ stress responses should be prioritized.

Pro-Con Debate: Etomidate or Ketamine for Rapid Sequence Intubation in Pediatric Patients

The previously popular alternative for sedation during endotracheal intubation, etomidate, has fallen out of favor due to its effects on adrenal function. Although there is limited evidence-based medicine to clearly demonstrate that etomidate increases mortality in patients with sepsis, current guidelines caution against its use in this population. Outside of patients with presumed sepsis, etomidate should be considered when choosing an agent for sedation during endotracheal intubation

The EvK Clinical Trial: Etomidate vs. Ketamine For Emergency Endotracheal Intubation

In this single-center RCT, critically ill patients who received ketamine for rapid-sequence induction had > 7-day survival over those who received etomidate. The tradeoff was more rescue therapy with vasopressors due to cardiovascular collapse in patients in the ketamine arm so be prepared to have vasopressors ready if electing to use ketamine.

We're Off To Never-Never Land – But Should We Use Etomidate for Rapid Sequence Intubation?

We would have been less definitive and more uncertain with our conclusions. The data suggests a single dose of etomidate may increase mortality in the short-term setting for critically ill adults although further research is needed to determine its effects on long-term mortality.