Van Berkel MA, Exline MC, Cape KM, et al. Journal of Critical Care. 2017; 38: 209-14.
Study Question: Does etomidate have a higher incidence of clinical hypotension compared to ketamine within the first 24 hours of intubation in adult patients with sepsis?
Study Description: This retrospective, single-center, propensity-matched cohort study included adult patients diagnosed with sepsis that received either ketamine or etomidate for endotracheal intubation. The primary outcome was incidence of clinical hypotension at any time point throughout the first 24 hours post-intubation. Clinical hypotension was defined as either MAP decreased > 40% from baseline and MAP < 70 mmHg, MAP < 60 mmHg, initiation of a vasopressor, or increase to > 30% of the initial vasopressor dose.
Results: A total of 384 patients were included. At baseline, patients that received ketamine had lower MAP (78 vs. 85 mmHg, p = 0.0001) and were diagnosed with septic shock (14.7 vs 6.5%, p = 0.046). Development of clinical hypotension 24 hours after intubation was not significantly different patients receiving etomidate compared to ketamine (67.5 vs 59%, p = 0.09). Etomidate was associated with a greater MAP reduction when comparing baseline to lowest MAP 24 hours post-intubation (-38 mmHg vs -27 mmHg, p = 0.001). After propensity matching, clinical hypotension at any time point post-intubation was higher with etomidate versus ketamine (OR 0.39; 95% CI 0.22-0.67). Statistical significance was appreciated at time periods 6.1-12 hours (65.1 vs. 69.3 mm Hg, p = 0.01) and 12.1-24 hours (63.9 vs. 68.4 mm Hg, p = 0.003).
Conclusion(s): Ketamine was associated with a lower incidence of clinical hypotension 24 hours after endotracheal intubation of adult medical ICU patients diagnosed with sepsis.
Perspective: This is the first study to perform a direct comparison on the hemodynamic effects of etomidate and ketamine in patients with sepsis. Bias was minimized and cofounders balanced through propensity score matching, although external validity remains limited given the single-center, retrospective approach. Residual selection bias of ketamine in patients with baseline hypotension or sepsis may be difficult to control for. Ketamine does appear to have positive hemodynamic benefits in this population up to 24 hours post intubation. Further study is needed in broader critically ill patients as well as determining the long-term impact of sedation choice during intubation.