Patients in the emergency department (ED) who require urgent tracheal intubation frequently have various physiologic abnormalities, which increases their risk of developing post-intubation hypotension. Previous studies demonstrated an independent relationship between post-intubation hypotension and increased morbidity and death. Post-intubation hypotension may be correlated with the choice of induction agent. It was debatable whether etomidate or ketamine is more effective in the context of hemodynamic instability, despite the fact that they are two of the most frequently utilized medications in emergency rooms. For a study, researchers sought to ascertain if patients who underwent intubation with either ketamine or etomidate experienced a different rate of post-intubation hypotension. They also conduct a subgroup analysis of patients with a history of cardiovascular collapse (defined as pre-intubation shock index (SI) > 0.9) to see if there are any changes in post-intubation hypotension rates among these high-risk patients based on the sedative selected for tracheal intubation. In individuals who take ketamine as opposed to etomidate, they believed that there was no difference in the incidence of post-intubation hypotension.
An extensive academic health system database of 469 individuals who had emergency intubation with either etomidate or ketamine induction underwent a retrospective cohort analysis. Between January 1, 2016, and June 30, 2019, patients were located via an automated search of electronic health records. Patients less than 18 years, tracheal intubations conducted outside of the ED, insufficient peri-intubation vital signs, or cardiac arrest occurring before intubation were excluded from the study. A pre-intubation SI>0.9 allowed for the identification of patients who were at high risk for hemodynamic collapse during the post-intubation interval. The incidence of post-intubation hypotension (systolic blood pressure <90 mmHg or mean arterial pressure <65 mmHg) was the main outcome. Mortality and post-intubation vasopressor usage were secondary outcomes. These analyses were run on the whole cohort as well as a subset of patients with SI > 0.9 in an exploratory study. In order to identify independent factors connected to post-intubation hypotension, they also present adjusted odds ratios (aOR) using a multivariable logistic regression model of the full cohort, correcting for probable confounding variables.
There were 358 patients in all (etomidate: 272; ketamine: 86). The group that got ketamine had a higher mean pre-intubation SI than the group that received etomidate (0.97 vs. 0.83, difference: -0.14 (95%, CI -0.2 to -0.1). Prior to SI categorization, the incidence of post-intubation hypotension was higher in the ketamine group (difference: -10%, 95% CI -20.9% to -0.1%). Patients with SI > 0.9 were more likely to receive ketamine from emergency room doctors. The choice of induction drug was not linked to post-intubation hypotension in our multivariate logistic regression study (aOR 1.45, 95% CI 0.79 to 2.65). The best indicator of post-intubation hypotension, according to the research, was the pre-intubation shock index.
Ketamine was utilized more frequently in the group of patients requiring urgent tracheal intubation for those who had a high shock index. They could not find a link between the frequency of post-intubation hypotension and either ketamine or etomidate as the induction drug. Regardless of whether ketamine or etomidate was used, patients with a high shock index were more likely to experience a cardiovascular collapse.
Reference: sciencedirect.com/science/article/pii/S0735675722005587
