In this episode, I’ll discuss the incidence of hypotension for etomidate vs ketamine during rapid sequence intubation.
Hypotension is an undesirable effect of rapid sequence intubation, and can occur from the medications used to facilitate intubation or from decreased venous return due to positive pressure ventilation.
Because ketamine has a side effect profile that includes hypertension and tachycardia, it is assumed that when used for sedation during rapid sequence intubation that ketamine will have a lower incidence of hypotension. Some prospective studies support this premise.
However 2 recent studies that analyzed the National Emergency Airway Registry suggest that ketamine might not be associated with lower rates of hypotension when compared to etomidate.
The first study involved 738 patients with ketamine and 6,068 with etomidate who required intubation in the emergency department. Peri‐intubation hypotension incidence was higher among patients receiving ketamine than patients receiving etomidate by an absolute difference of 5.9%. Patients receiving ketamine were also more likely to receive treatment for peri‐intubation hypotension by an absolute difference of 6.4%. These effects held up even after logistic regression analysis. The dose of ketamine or etomidate did not seem to have an effect on the incidence of hypotension.
The second study of the same database focused on 531 patients who had sepsis and required intubation. Etomidate was used in about 70% of these patients. Post intubation hypotension was higher in those intubated for sepsis with ketamine by an absolute difference of 24% compared to etomidate. This difference held up to propensity-score adjustment.
These two studies raise the possibility that ketamine might not have the lower peri-intubation hypotension risk that it is thought to, although a randomized trial would be needed to conclude this with certainty. Patients with hypotension that existed before the intubation procedure were not included in the dataset for the larger trial. In addition, when just trauma patients were examined, there was no difference between groups in hypotension incidence.
Members of my Hospital Pharmacy Academy have access to practical training on airway pharmacology and the use of ketamine in critical care from a pharmacist’s point of view, along with many other resources to help in your practice. To get immediate access, go to pharmacyjoe.com/academy.
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