COMMENTARY

Etomidate vs Ketamine in Emergent Intubation: A Commentary by Greg S. Martin, MD, MSc

Gregory S. Martin, MD, MSc

Disclosures

September 08, 2009

Etomidate Versus Ketamine for Rapid Sequence Intubation in Acutely Ill Patients: A Multicentre Randomised Controlled Trial

Jabre P, Combes X, Lapostolle F, et al; on behalf of the KETASED Collaborative Study Group
Lancet. 2009;374:293-300

Summary

Patients developing critical illness often require endotracheal intubation. Etomidate use has been questioned because of its ability to cause reversible adrenal insufficiency, which may be of particular importance in critically ill patients or those in shock. Ketamine use has risen again, despite prior concerns about psychotropic effects and hallucinatory "emergence reactions" in 10%-20% of adults. The study authors sought to compare the use of etomidate and ketamine for rapid sequence endotracheal intubation in critically ill patients. Six hundred fifty-five patients in France were randomized to receive etomidate (0.3 mg/kg) or ketamine (2 mg/kg) as part of rapid sequence induction and endotracheal tube placement for management of acute respiratory failure. Four hundred sixty-nine patients were analyzed, with no serious adverse events in either group and only small differences between groups in age, sex, and illness severity at baseline. Comparing the 2 groups, there was no difference in maximum Sequential Organ Failure Assessment (SOFA) score (a measure of organ dysfunction in acute illness), 28-day mortality, shock status, mechanical ventilation requirements, or intensive care unit length of stay. The proportion of patients identified as having adrenal insufficiency was significantly higher in the etomidate group (86% vs 48%, odds ratio 6.7, P < .05). The authors concluded that ketamine is a safe alternative to etomidate for rapid sequence induction and endotracheal intubation in critically ill patients, and thus should be considered in those with sepsis.

Viewpoint

The optimal agent of choice for emergent intubation of critically ill patients has been an area of growing controversy over the last few years. In particular, because etomidate may induce a state of pharmacologic adrenalectomy, its use has been of concern in severely ill patients and those with shock. The publication of studies questioning the safety of etomidate use in critically ill children with meningococcemia[1] and adults with septic shock,[2] as well as trauma patients,[3,4] has prompted intensivists worldwide to reduce the use of etomidate and to seek alternatives to achieve rapid sedation for intubation. The current study does not address the safety of etomidate use, and clearly documents the increased risk of causing adrenal dysfunction with etomidate administration. The study does, however, suggest that ketamine may be a useful alternative to etomidate for rapid intubation in critically ill patients. The common effects of ketamine must be considered before use in critically ill patients: elevations in blood pressure and heart rate; nausea and vomiting; and bronchodilation. However, the common concerning side effect of "emergence reactions" or "psychodysleptic effects" (psychedelic reactions) may be of less concern in patients in the intensive care unit who will receive other sedative, hypnotic, and analgesic medications after intubation and thus not experience the potential psychological effects of ketamine. It is unfortunate that the current study did not query patients for these effects after recovery and awakening from the common sedation required in intubated patients.

Abstract

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