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Ketamine for the Win? Induction Agents Compared

March 15, 2024

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Written by Charles Worth and Ketan Patel

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A Bayesian meta-analysis found an 83.2% probability that ketamine lowers mortality compared to etomidate in critically ill patients undergoing intubation.

Maybe she’s born with it…maybe it’s ketamine.
Current practice guidelines for RSI agents include propofol, etomidate and ketamine. This analysis aimed to identify whether there was a likelihood of decreased mortality by using ketamine over the respective other agents. Propofol has well known cardiovascular effects, and etomidate has been associated with adrenal insufficiency. The authors were able to identify 7 RCTs and one propensity matched study of ketamine to etomidate but no studies that included propofol.

The primary outcome was all-cause mortality, with a 1% absolute risk reduction considered clinically significant. The studies included a total of 2,978 critically ill adult patients. Bayesian analysis found the estimated probability that ketamine reduces mortality when compared to etomidate to be 83.2%, with a probability of 1% absolute risk reduction being 62.2%.

The pooled data from the RCTs were unable to show any statistically significant secondary outcomes. It is unknown if delayed adrenal suppression related to etomidate contributed to the mortality increase. Peri-intubation interventions were not standardized (opioids, paralytics, vasopressors) in the included studies. However, they included a large sample size, low risk of bias, usage of high quality RCTs (in large part), and a moderate probability outcome achieved.

How will this change my practice?
Given that this meta-analysis found an 83.2% probability that ketamine results in a lower mortality than etomidate, and the known downsides of etomidate and propofol, I will likely adjust my induction agent to strongly favor ketamine in the future.

Peer Reviewed by Dr. Ketan Patel

Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care. 2024 Feb 17.

What are your thoughts?