Journal Article

Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial

Anguel, Nadia, Maxime, Virginie, Bertrand, Lionel, Lapostolle, Frederic, Albizzati, Stephane, Chollet-Xemard, Charlotte, Megarbane, Bruno, Ricard, Jean-Damien, Adnet, Frederic, Vicaut, Eric, Brun-Buisson, Christian, Lebail, Gaelle, Lefrant, Jean-Yves, Jabre, Patricia, Dhaouadi, Mohamed, Ricard-Hibon, Agnes, Gamand, Pascale, Perdrizet, Deborah, Combes, Xavier, Vivien, Benoit, Bollaert, Pierre-Edouard, Beltramini, Alexandra

2009

Overview

Critically ill patients often require emergency intubation. The use of etomidate as the sedative agent in this context has been challenged because it might cause a reversible adrenal insufficiency, potentially associated with increased in-hospital morbidity. We compared early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients. In this randomised, controlled, single-blind trial, 655 patients who needed sedation for emergency intubation were prospectively enrolled from 12 emergency medical services or emergency departments and 65 intensive care units in France. Patients were randomly assigned by a computerised random-number generator list to receive 0·3 mg/kg of etomidate (n=328) or 2 mg/kg of ketamine (n=327) for intubation. Only the emergency physician enrolling patients was aware of group assignment. The primary endpoint was the maximum score of the sequential organ failure assessment during the first 3 days in the intensive care unit. We excluded from the analysis patients who died before reaching the hospital or those discharged from the intensive care unit before 3 days (modified intention to treat). This trial is registered with ClinicalTrials.gov, number NCT00440102. 234 patients were analysed in the etomidate group and 235 in the ketamine group. The mean maximum SOFA score between the two groups did not differ significantly (10·3 [SD 3·7] for etomidate vs 9·6 [3·9] for ketamine; mean difference 0·7 [95% CI 0·0–1·4], p=0·056). Intubation conditions did not differ significantly between the two groups (median intubation difficulty score 1 [IQR 0–3] in both groups; p=0·70). The percentage of patients with adrenal insufficiency was significantly higher in the etomidate group than in the ketamine group (OR 6·7, 3·5–12·7). We recorded no serious adverse events with either study drug. Our results show that ketamine is a safe and valuable alternative to etomidate for endotracheal intubation in critically ill patients, and should be considered in those with sepsis. French Ministry of Health.

• Publisher: Elsevier Ltd,Elsevier,Elsevier Limited
• Subject: Adrenal Insufficiency - chemically induced / Adrenal Insufficiency - epidemiology / Aged / Anesthetics, Intravenous - adverse effects / Anesthetics, Intravenous - therapeutic use / Biological and medical sciences / Cardiology and cardiovascular system / Clinical trials / Critical care / Critical Illness - mortality / Critical Illness - therapy / Emergency medical services / Emerging diseases / Etomidate - adverse effects / Etomidate - therapeutic use / Female / France - epidemiology / General aspects / Hospitals / Human health and pathology / Humans / Infectious diseases / Injections, Intravenous / Intensive care / Internal Medicine / Intubation, Intratracheal - adverse effects / Intubation, Intratracheal - methods / Kaplan-Meier Estimate / Ketamine - therapeutic use / Life Sciences / Male / Medical sciences / Middle Aged / Morbidity / Mortality / Multiple Organ Failure - epidemiology / Multiple Organ Failure - etiology / Patients / Prescription drugs / Prospective Studies / Pulmonology and respiratory tract / Single-Blind Method / Toxicology / Treatment Outcome