PREGUNTA CLÍNICA: ¿QUÉ AGENTE DE INDUCCIÓN TIENE MEJOR SUPERVIVENCIA DÍA 7 PARA PACIENTES CRÍTICOS QUE REQUIEREN INTUBACIÓN ENDOTRAQUEAL DE URGENCIA, KETAMINA O ETOMIDATO?
Referencia: Matchett, G. et al. Etomidato versus ketamina para la intubación endotraqueal de emergencia: un ensayo clínico aleatorizado. Medicina de cuidados intensivos 2021
Población: Adultos de 18 años de edad y mayores que necesitan intubación endotraqueal (ET) de emergencia
Exclusiones: niños, pacientes embarazadas, pacientes que necesitan intubación ET sin sedación o alérgicos a uno de los agentes que se utilizan
Intervención: Ketamina 1-2mg/kg IV
Comparación: etomidato 0,2-0,3 mg/kg IV
Salir:
Resultado primario: supervivencia de 7 días
Resultados secundarios: supervivencia a los 28 días, duración de la ventilación mecánica, duración de la estancia en la UCI, necesidad de uso de vasopresores, puntajes SOFA y una evaluación de un nuevo diagnóstico de insuficiencia suprarrenal por parte de los equipos de cuidados intensivos tratantes.
Ensayo: Ensayo prospectivo, aleatorizado, de asignación paralela, abierto, de un solo centro (NCT02643381)
Conclusiones de los autores: si bien el resultado primario de supervivencia el día 7 fue mayor en los pacientes asignados al azar a la ketamina, no hubo una diferencia significativa en la supervivencia el día 28".
#víaaérea #paramedicina #medicinadeemergencia #anastesia
https://clinicaltrials.gov/ct2/show/NCT02643381
https://www.anesthesiologynews.com/Airway-Management/Article/12-21/Ketamine-Improves-1-Week-Survival-After-Emergency-Intubation/65376
CLINICAL QUESTION: WHICH INDUCTION AGENT HAS A BETTER DAY 7 SURVIVAL FOR CRITICALLY ILL PATIENTS REQUIRING EMERGENCY ENDOTRACHEAL INTUBATION, KETAMINE OR ETOMIDATE?
Reference: Matchett, G. et al. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med 2021
Population: Adults 18 years of age and older in need of emergency endotracheal (ET) intubation
Exclusions: Children, pregnant patients, patients needing ET intubation without sedation or allergic to one of the agents being used
Intervention: Ketamine 1-2mg/kg IV
Comparison: Etomidate 0.2-0.3mg/kg IV
Outcome:
Primary Outcome: 7-day survival
Secondary Outcomes: 28-day survival, duration of mechanical ventilation, ICU length of stay, need for vasopressor use, SOFA scores and an assessment of a new diagnosis of adrenal insufficiency by the treating critical care teams.
Trial: Prospective, randomized, parallel-assignment, open-label, single-center trial (NCT02643381)
Authors’ Conclusions: While the primary outcome of Day 7 survival was greater in patients randomized to ketamine, there was no significant difference in survival by Day 28.”
#airway #paramedicine #emergencymedicine #anasthesia
Rob J. Bryant, MD
Emergency Medicine Faculty
Utah Emergency Physicians
Twitter: @RobJBryant13
Objectives
- Review current evidence in the use of Etomidate or Ketamine in patients with hemodynamic compromise requiring intubation
- Be able to defend your choice of Etomidate or Ketamine in patients requiring RSI
Outline
- Review RSI approaches using standard, and reduced dose Ketamine and Etomidate
- Review NEAR registry data on recent ED use of these agents
- Discuss limitations of observational studies
Ketamine vs Etomidate for RSI
- Mohr et al. Acad Emerg Med 2020. PMID: 32602974
- NEAR Cohort Registry Study
- Ketamine vs Etomidate in sepsis
- ≈500 patients: ≈250 etomidate vs ≈140 ketamine
- Primary Outcome: SBP <100mmHg within 15min of intubation
- Ketamine = 74% vs Etomidate 50%
- Vasopressor use within 15min of intubation
- Ketamine = 30% vs Etomidate = 23%
- Registry studies at best can show us trends and should be used as hypothesis generating trials and nothing more
- Without controlling for why a particular agent was used it is impossible to say if one agent was used in a sicker cohort compared to the other (Why was ketamine used instead of etomidate or vice versa?)
- Study doesn’t answer the question of reduced dose induction agents
- Critical Care 2015. PMID: 25879683
- Physiologically unstable trauma patients
- Etomidate 0.15mg/kg + 1.5mg/kg succinylcholine + 1mg/kg rocuronium vs Fentanyl 1mcg/kg + 1mg/kg ketamine + 1mg/kg rocuronium
- No difference in post intubation hypotension
- April et al. Acad Emerg Med 2020. PMID: 32592205
- NEAR Cohort Registry Study
- Ketamine <1mg/kg vs >1mg/kg and Etomidate <0.3mg/kg vs >0.3mg/kg
- ≈6800 patients: Etomidate ≈6,000pts and Ketamine ≈700pts
- Primary Outcome: Peri-intubation hypotension in all intubations (SBP <100mmHg within 15min of intubation)
- Ketamine = 18.3% and Etomidate = 12.4%
- SBP <100mmHg within 15min of intubation in trauma patients
- No difference between ketamine and etomidate
- SBP <100mmHg within 15 min of intubation in dose reduced vs standard dose strategies
- Groups were unbalanced:
- More pts with sepsis in ketamine group
- Ketamine 19.9% and Etomidate 10.9%
- More pts with difficult airway characteristics in ketamine group
- Ketamine 69.2% and Etomidate 60.4%
- Jabre et al. Lancet 2009. PMID: 19573904
- Blinded Randomized Controlled Trial in France
- 655 critically ill patients
- Etomidate 0.3mg/kg vs 2mg/kg Ketamine
- Pre and Post Intubation Blood Pressure
- Etomidate: 5mmHg (-11 to 30)
- Ketamine: 10mmHg (-10 to 33)
- No statistical difference between groups
Bottom Line:
- Both NEAR trials were registry studies which do not allow for direct comparison of ketamine vs etomidate without randomization. Without randomization, the granular details of why a particular agent or dose of agent was chosen will lead to confounding factors that will give false conclusions
- Highest level evidence (Jabre et al) shows no difference in post-intubation hypotension rate (Ketamine = Etomidate)
- In “Big Sick” patients (Hemodynamically unstable), consider using reduced dose induction agents and a delayed sequence strategy to ensure patient is appropriately sedated before giving paralytics
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)
Cite this article as: Salim Rezaie, "Rebellion21: Ketamine vs Etomidate for RSI via Rob J. Bryant, MD", REBEL EM blog, September 22, 2021. Available at: https://rebelem.com/rebellion21-ketamine-vs-etomidate-for-rsi-via-rob-j-bryant-md/.
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