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Etomidate vs Ketamine…Again – Which is Worse for Post-Intubation Hypotension?

October 5, 2022

Written by Joshua Campbell

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This study showed no difference in post-intubation hypotension for endotracheal intubations in the ED between ketamine and etomidate.

Why does this matter?
ED intubations are incredibly common, and post-intubation hypotension is a real issue. Which drug causes the fewest problems post-intubation?

A tale as old as time…
We are back at it again, addressing the age old question of etomidate vs ketamine—which is better? This was a retrospective cohort study on a database at a single, large center. The goal was to assess whether there was a difference in the rate of post-intubation hypotension in those who received either ketamine or etomidate for intubation. The investigators looked at the incidence of post-intubation hypotension (SBP <90 or MAP <65), as well as post-intubation vasopressor use and mortality. Primary analysis was performed on the entire cohort and secondary analysis on patients with a shock index (SI) >0.9. This is thought to be the first study that accounted for SI when comparing post-intubation hypotension between these two drugs. A total of 358 patients were included, with 272 receiving etomidate and 86 receiving ketamine.

Prior to SI stratification, post-intubation hypotension was documented in 28% of ketamine inductions vs 18% of etomidate inductions. However, with SI stratification there was no difference in post-intubation hypotension. Interestingly, the mean SI for ketamine was 0.97 vs 0.83 for etomidate. This suggests that ED providers were more likely to use ketamine for more hemodynamically unstable patients.

My takeaway: In this study, there was no appreciable difference in post-intubation hypotension between etomidate and ketamine when controlled for SI. An elevated pre-intubation shock index (>0.9) was the strongest predictor of post-intubation hypotension. It continues to look like either of these medications is an acceptable choice in many clinical scenarios and, as always, the sicker the patient, the worse the outcomes tend to be.

Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation. Am J Emerg Med. 2022 August;61: 131-136. doi: 10.1016/j.ajem.2022.08.054

What are your thoughts?