Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults.

Summary

In a multicenter RCT of 2365 critically ill adults, ketamine did not reduce 28-day in-hospital mortality compared to etomidate for rapid sequence induction. Cardiovascular collapse during intubation was more frequent with ketamine, while other safety outcomes were similar.

Key Findings

• 28-day in-hospital mortality: ketamine 28.1% vs etomidate 29.1% (adjusted risk difference -0.8 percentage points; 95% CI -4.5 to 2.9; P=0.65).
• Cardiovascular collapse during intubation was higher with ketamine (22.1%) than etomidate (17.0%); risk difference 5.1 percentage points (95% CI 1.9 to 8.3).
• Prespecified safety outcomes aside from cardiovascular collapse were similar between groups.

Clinical Implications

Etomidate remains a reasonable induction agent for RSI in critically ill adults. Ketamine should not be chosen with the expectation of mortality benefit and may increase the risk of cardiovascular collapse during intubation; hemodynamic vigilance is warranted.

Limitations

• Blinding to induction agent was likely not feasible, introducing potential performance bias.
• Practice heterogeneity across ED and ICU settings could influence outcomes despite randomization.

Future Directions

Subgroup analyses by shock phenotype and vasopressor use, and pragmatic trials evaluating protocolized hemodynamic support during RSI may refine agent selection.