Efficacy and safety of esketamine for emergency endotracheal intubation in ICU patients: a double-blind, randomized controlled clinical trial.

Summary

In a double-blind RCT of 80 ICU patients requiring emergency intubation, esketamine maintained higher MAP during and after induction without increasing heart rate, reduced norepinephrine requirements, and significantly shortened ventilation duration and ICU length of stay. No difference in 28-day mortality or serious adverse events was observed.

Key Findings

• Esketamine maintained higher MAP during induction and at 1, 5, and 10 minutes post-intubation compared with midazolam/sufentanil.
• Ventilation duration was reduced (median 105.3 vs 211.5 hours, P=0.002) and ICU length of stay shortened (median 7.0 vs 15.0 days, P=0.002).
• Norepinephrine requirements were lower with esketamine; heart rate and 28-day mortality were not different and no serious adverse events occurred.

Clinical Implications

Consider esketamine as an induction agent for emergency intubations in hemodynamically fragile ICU patients to reduce vasopressor requirements, ventilation duration, and ICU stay, while monitoring for standard ketamine class effects.

Limitations

• Single-center study with modest sample size (n=80)
• No difference in 28-day mortality; not powered for hard endpoints

Future Directions

Larger multicenter RCTs comparing esketamine to etomidate/ketamine/propofol across phenotypes (shock, sepsis, TBI), with standardized co-induction and neuromuscular blockade, and longer-term neurologic and mortality outcomes.