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Episode 936: Etomidate vs. Ketamine for Rapid Sequence Intubation

Emergency Medical Minute

Release Date: 12/23/2024

Episode 936: Etomidate vs. Ketamine for Rapid Sequence Intubation show art Episode 936: Etomidate vs. Ketamine for Rapid Sequence Intubation

Emergency Medical Minute

Contributor: Ricky Dhaliwal MD Educational Pearls:  Etomidate was previously the drug of choice for rapid sequence intubation (RSI) However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity A recent meta-analysis analyzing etomidate as an induction agent showed the following: 11 randomized-controlled trials with 2704 patients Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death The probability of any mortality increase was 98.1% ...

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Contributor: Ricky Dhaliwal MD

Educational Pearls: 

  • Etomidate was previously the drug of choice for rapid sequence intubation (RSI)

    • However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity

  • A recent meta-analysis analyzing etomidate as an induction agent showed the following:

    • 11 randomized-controlled trials with 2704 patients

    • Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death

    • The probability of any mortality increase was 98.1%

  • Ketamine is preferable due to a better adverse effect profile

    • Laryngeal spasms and bronchorrhea are the most common adverse effects after IV push

    • Beneficial effects on hemodynamics via catecholamine surge, albeit not as pronounced in shock patients

  • 2023 meta-analysis compared ketamine and etomidate for RSI

    • Ketamine’s probability of reducing mortality is cited as 83.2%

    • Overall, induction with ketamine demonstrates a reduced risk of mortality compared with etomidate

  • The dosage of each medication for induction

    • Etomidate: 20 mg based on 0.3 mg/kg for a 70 kg adult

    • Ketamine: 1-2 mg/kg (or 0.5-1 mg/kg in patients with shock)

  • Patients with asthma and/or COPD also benefit from ketamine induction due to putative bronchodilatory properties

References

  1.  Goyal S, Agrawal A. Ketamine in status asthmaticus: A review. Indian J Crit Care Med. 2013;17(3):154-161. doi:10.4103/0972-5229.117048

  2. Koroki T, Kotani Y, Yaguchi T, et al. Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care. 2024;28(1):1-9. doi:10.1186/s13054-024-04831-4

  3. Kotani Y, Piersanti G, Maiucci G, et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. J Crit Care. 2023;77(April 2023):154317. doi:10.1016/j.jcrc.2023.154317

Summarized & Edited by Jorge Chalit, OMS3

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