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EvK Trial – Etomidate vs Ketamine for RSI

January 24, 2022

Written by Clay Smith

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In this single-center RCT, 7-day survival was lower with etomidate than ketamine, 77.3% vs 85.1%.

Why does this matter?
KETASED found no statistical difference in maximum SOFA score or hemodynamic variables comparing ketamine to etomidate. A 2015 meta-analysis of RCTs found single-dose etomidate for induction was associated with transiently abnormal cortrosyn stimulation testing but not increased short-term mortality. However, a newer meta-analysis that included observational studies raised concern about a possible adverse mortality impact. So, what happens to short-term mortality in an RCT?

Head to head at last
A QI project at UT Southwestern in Dallas also raised concern that mortality was higher among inpatients who needed emergency non-OR airway team response and received etomidate for RSI, which prompted this double blinded RCT in 801 critically ill inpatients. They compared standard RSI doses of etomidate and ketamine and found 7-day survival was statistically and clinically significantly lower in the etomidate group compared with ketamine 77.3% (90/396) vs 85.1% (59/395), respectively; NNH = 13. However, by day 28 the survival rate for etomidate vs ketamine groups was no longer statistically different: 64.1% (142/396) vs 66.8% (131/395). Not that it seemed to matter, but the ketamine group had more hypotension – just sayin’ (though not statistically significant, similar to KETASED).

This study answers one question but raises others. Here are two. Why did short-term mortality increase? Why did mortality in the ketamine group almost “catch up” with the etomidate group at 28 days? Regardless, it affirms my practice of ketamine as firstline in the ED for RSI.

Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med. 2021 Dec 14. doi: 10.1007/s00134-021-06577-x. Online ahead of print.