Episode 936: Etomidate vs. Ketamine for Rapid Sequence Intubation

Contributor: Ricky Dhaliwal MD

Educational Pearls: 

• Etomidate was previously the drug of choice for rapid sequence intubation (RSI)

  • However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity

• A recent meta-analysis analyzing etomidate as an induction agent showed the following:

  • 11 randomized-controlled trials with 2704 patients

  • Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death

  • The probability of any mortality increase was 98.1%

• Ketamine is preferable due to a better adverse effect profile

  • Laryngeal spasms and bronchorrhea are the most common adverse effects after IV push

  • Beneficial effects on hemodynamics via catecholamine surge, albeit not as pronounced in shock patients

• 2023 meta-analysis compared ketamine and etomidate for RSI

  • Ketamine’s probability of reducing mortality is cited as 83.2%

  • Overall, induction with ketamine demonstrates a reduced risk of mortality compared with etomidate

• The dosage of each medication for induction

  • Etomidate: 20 mg based on 0.3 mg/kg for a 70 kg adult

  • Ketamine: 1-2 mg/kg (or 0.5-1 mg/kg in patients with shock)

• Patients with asthma and/or COPD also benefit from ketamine induction due to putative bronchodilatory properties

References

1.  Goyal S, Agrawal A. Ketamine in status asthmaticus: A review. Indian J Crit Care Med. 2013;17(3):154-161. doi:10.4103/0972-5229.117048

2. Koroki T, Kotani Y, Yaguchi T, et al. Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care. 2024;28(1):1-9. doi:10.1186/s13054-024-04831-4

3. Kotani Y, Piersanti G, Maiucci G, et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. J Crit Care. 2023;77(April 2023):154317. doi:10.1016/j.jcrc.2023.154317

Summarized & Edited by Jorge Chalit, OMS3

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