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Meta-Analysis
. 2025 Feb 1;53(2):e374-e383.
doi: 10.1097/CCM.0000000000006515. Epub 2024 Nov 21.

Ketamine Versus Etomidate for Rapid Sequence Intubation: A Systematic Review and Meta-Analysis of Randomized Trials

Alisha Greer  1   2 , Mark Hewitt  1   2 , Parsa T Khazaneh  2 , Begum Ergan  3 , Lisa Burry  4   5 , Matthew W Semler  6 , Bram Rochwerg  2   7 , Sameer Sharif  1   2   7
Affiliations
Meta-Analysis

Ketamine Versus Etomidate for Rapid Sequence Intubation: A Systematic Review and Meta-Analysis of Randomized Trials

Alisha Greer et al. Crit Care Med. .

Abstract

Objectives: To compare the safety and efficacy of ketamine and etomidate as induction agents to facilitate emergent endotracheal intubation.

Data sources: We searched MEDLINE, Embase, Cochrane Clinical Trials Register, and ClinicalTrials.gov from inception to April 3, 2024.

Study selection: We included randomized controlled trials (RCTs) that compared ketamine to etomidate to facilitate emergent endotracheal intubation in adults.

Data extraction: Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model, assessed risk of bias using the modified Cochrane tool and certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We pre-registered the protocol on PROSPERO (CRD42023472450).

Data synthesis: We included seven RCTs ( n = 2384 patients). Based on pooled analysis, compared with etomidate, ketamine probably increases hemodynamic instability in the peri-intubation period (relative risk [RR], 1.29; 95% CI, 1.07-1.57; moderate certainty) but probably decreases the need for initiation of continuous infusion vasopressors (RR, 0.75; 95% CI, 0.57-1.00; moderate certainty) and results in less adrenal suppression (RR, 0.54; 95% CI, 0.45-0.66; moderate certainty). Ketamine probably has no effect on successful intubation on the first attempt (RR, 1.01; 95% CI, 0.97-1.05; moderate certainty) or organ dysfunction measured as the maximum Sequential Organ Failure Assessment (SOFA) score during the first 3 days in ICU (mean difference, 0.55 SOFA points lower; 95% CI, 1.12 lower to 0.03 higher; moderate certainty) and may have no effect on mortality (RR, 1.00; 95% CI, 0.83-1.21; low certainty) when compared with etomidate.

Conclusions: Compared with etomidate, ketamine probably results in more hemodynamic instability during the peri-intubation period and appears to have no effect on successful intubation on the first attempt or mortality. However, ketamine results in decreased need for the initiation of vasopressor use and decreases adrenal suppression compared with etomidate.

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Conflict of interest statement

Dr. Semler received support for article research from the National Institutes of Health. Dr. Sharif received funding from the McMaster University Department of Medicine Internal Career Research Award. The remaining authors have disclosed that they do not have any potential conflicts of interest.

References

    1. Smischney NJ, Demirci O, Diedrich DA, et al.: Incidence of and risk factors for post-intubation hypotension in the critically ill. Medical Sci Monit. 2016; 22:346–355
    1. Watt I, Ledingham IM: Mortality amongst multiple trauma patients admitted to an intensive therapy unit. Anaesthesia. 1984; 39:973–981
    1. Raff H, Sharma ST, Nieman LK: Physiological basis for the etiology, diagnosis, and treatment of adrenal disorders: Cushing’s syndrome, adrenal insufficiency, and congenital adrenal hyperplasia. Compr Physiol. 2014; 4:739–769
    1. April MD, Arana A, Schauer SG, et al.; NEAR Investigators: Ketamine versus etomidate and peri-intubation hypotension: A national emergency airway registry study. Acad Emerg Med. 2020; 27:1106–1115
    1. Prekker Matthew E, Driver Brian E, Trent Stacy A, et al.: Video versus direct laryngoscopy for tracheal intubation of critically ill adults. N Engl J Med. 2023; 389:418–429

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