KETAMINE VS ETOMIDATE FOR RAPID SEQUENCE INTUBATION IN THE CRITICALLY ILL POPULATION

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SESSION TITLE: Endotracheal Intubation: Getting In and Getting Out SESSION TYPE: Original Investigations PRESENTED ON: 10/23/2019 10:45 AM - 11:45 AM PURPOSE: Etomidate and ketamine are both used for sedation in rapid sequence intubation (RSI). Early studies reported few adverse pulmonary or cardiovascular effects with etomidate use, but recent work describes potential increased mortality secondary to adrenal suppression, and possible hypotension with etomidate use in critically ill patients. Ketamine has, thus, been suggested as an alternative agent. Few studies have compared outcomes for ketamine vs. etomidate for RSI, and results are conflicting. Given the paucity of literature, and controversy over best agent, we compared outcomes with ketamine vs. etomidate for RSI in the critical care setting. METHODS: A multi-center retrospective cohort study was conducted on patients aged 18 and older who underwent rapid sequence intubation (RSI) between 1/1/2017 and 12/31/2017. Outcomes of interest included post-RSI hypotension, hospital length of stay, ventilator days, in-hospital death, and post-RSI cardiac events (MI, CVA, or cardiac arrest). RESULTS: Of 842 identified patients, 808 were exposed to etomidate and 34 to ketamine as part of RSI. There were no differences in patient characteristics or comorbidities between groups. Post-RSI hypotension was lower in those exposed to ketamine 41.2% vs. 57.0%, p = 0.078. After controlling for concurrent medications (propofol, fentanyl, versed, levophed, vasopressin, and steroid use), ketamine was less likely to cause clinical hypotension compared to etomidate in patients with non-sepsis (OR = 0.28, 95% CI 0.10-0.79, p = 0.017) and in general overall (OR = 0.36, 95% CI 0.15-0.85, p = 0.019). However, in just the sepsis group, ketamine was insignificant (OR = 0.66, 95% CI 0.13-3.42, p = 0.619). There were no differences in length of stay, ventilator days, in-hospital death or post-RSI cardiac events between groups. CONCLUSIONS: Though ketamine was associated with less clinical hypotension when used in RSI, this did not translate to differences in patient outcomes. CLINICAL IMPLICATIONS: Concerns have been raised regarding etomidate use in RSI for patients with sepsis because of etomidate’s effect on the adrenal axis and potential to increase mortality. However, we found no meaningful difference in hospital complications, length of stay, or mortality, even in those patients who had sepsis. Given the small number of patients in our study, additional work is required to evaluate for drug superiority, specifically in patients with sepsis. DISCLOSURES: No relevant relationships by Jordan Arends, source=Web Response No relevant relationships by John Elliott, source=Web Response No relevant relationships by Kim Jordan, source=Web Response No relevant relationships by Vincent Kang, source=Web Response No relevant relationships by Gabrielle Sabino, source=Web Response No relevant relationships by Steven Wu, source=Web Response