In this episode, I’ll discuss whether there is an association between the sedative dose and postintubation hypotension and rapid sequence intubation.
When a patient who requires sedation for intubation also has hemodynamic instability, a common recommendation is to lower the dose of sedative given in hopes of preventing further hemodynamic compromise. This seems like a logical approach given the known side effects of many sedatives used in rapid sequence intubation include hemodynamic compromise. While the dose-dependent hypotension effects are well described for propofol, there is little evidence to support this concept for etomidate and ketamine.
Therefore a group of authors published a retrospective database review in Annals of Emergency Medicine to examine whether the dose of etomidate or ketamine was associated with post-intubation hypotension.
Over 12,000 intubations with etomidate and nearly 2000 with ketamine were analyzed. The median IV drug doses were 0.28 mg/kg for etomidate and 1.33 mg/kg for ketamine. Post-intubation hypotension occured in 16.2% of the etomidate group and 29% of the ketamine group. Multivariable adjustment was applied to address confounders however, in neither the etomidate nor ketamine group was the dose of sedative received associated with postintubation hypotension. Even when the analysis excluded patients with pre-intubation hypotension and focused only on patients intubated for shock, results were similar.
The authors concluded:
In this large registry of patients intubated after receiving either etomidate or ketamine, we observed no association between the weight-based sedative dose and postintubation hypotension.
It is important to note that although the raw percentages of patients who had post-intubation hypotension were nearly double in the ketamine group vs etomidate, the study was not designed or controlled for between-drug comparisons, and these results cannot be used to suggest that ketamine has a higher rate of post-intubation hypotension compared with etomidate.
To access my free download area with 20 different resources to help you in your practice, go to pharmacyjoe.com/free.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.