Abstract
To determine whether ketamine use for tracheal intubation, compared to other sedative use, is associated with a lower risk of post-intubation hypotension in hemodynamically-unstable patients in the emergency department (ED), we analyzed the data of a prospective, multicenter, observational study—the second Japanese Emergency Airway Network (JEAN-2) Study—from February 2012 through November 2017. The current analysis included adult non-cardiac-arrest ED patients with a pre-intubation shock index of ≥0.9. The primary exposure was ketamine use as a sedative for intubation, with midazolam or propofol use as the reference. The primary outcome was post-intubation hypotension. A total of 977 patients was included in the current analysis. Overall, 24% of patients developed post-intubation hypotension. The ketamine group had a lower risk of post-intubation hypotension compared to the reference group (15% vs 29%, unadjusted odds ratio [OR] 0.45 [95% CI 0.31–0.66] p < 0.001). This association remained significant in the multivariable analysis (adjusted OR 0.43 [95% CI 0.28–0.64] p < 0.001). Likewise, in the propensity-score matching analysis, the patients with ketamine use also had a significantly lower risk of post-intubation hypotension (OR 0.47 [95% CI, 0.31–0.71] P < 0.001). Our observations support ketamine use as a safe sedative agent for intubation in hemodynamically-unstable patients in the ED.
Highlights
Tracheal intubation for hemodynamically-unstable patients is a critical resuscitation procedure in the emergency department (ED)
We excluded 3,183 patients with cardiac arrest, 169 children, 2,361 patients with a shock index (SI) of
Product term of ketamine use–X–SI, both SI and product term were not significantly associated with the risk of post-intubation hypotension, indicating that the effect of ketamine use on the risk of post-intubation hypotension does not differ by the degree of pre-intubation hemodynamic stability. In this analysis of 977 adult hemodynamically-unstable patients who underwent intubation in the ED, we found that ketamine use as a sedative agent was associated with a significantly lower risk of post-intubation hypotension, compared with the reference group
Summary
The literature has documented that the adverse event rate in ED patients who underwent airway management remains high—e.g., 22% with post-intubation hypotension and up to 4% with cardiac arrest[1,2]. Building strong evidence base for intubation medications (e.g., sedative agents) is critical for the development of optimal intubation strategies in hemodynamically-unstable patients (e.g., patients with pre-intubation hypotension and shock) who are at high risk for these clinically-important adverse events[3]. There remains a controversy over the relationship of ketamine use with the risk of post-intubation hypotension in the ED. To address the knowledge gap in the literature, we analyzed the data from a large multicenter prospective study to determine the association of ketamine use—compared with midazolam or propofol use—with the risk of post-intubation hypotension in hemodynamically-unstable ED patients
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