Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicenter randomized controlled trial

Abstract

Introduction: Critically ill patients often require emergency intubation with administration of etomidate as the sedative agent. The use of etomidate has been challenged as it causes a reversible adrenal insufficiency probably leading to an increase in hospital morbidity. Methods: In this prospective, randomized, controlled, single-blind trial, we assigned 234 patients to receive 0.3 mg/kg etomidate and 235 patients to receive 2 mg/kg ketamine for intubation. The primary endpoint was the maximum value of the Sequential Organ Failure Assessment score (SOFA max) during the first inhospital 3 days. (ClinicalTrials.gov number, NCT00440102.) Results: The mean SOFA max score between the two groups was not significantly different (10.3 +/- 3.7 for etomidate vs. 9.6 +/- 3.9 for ketamine; P = 0.056). There was no significant difference in 28- day mortality (81 (35%) deaths vs. 72 (31%) deaths, P = 0.36), the number of patients needing catecholamine (137 (59%) patients vs. 120 (51%) patients, P = 0.10), median (IQR) ventilator-free days (12 (0 to 25) days vs. 15 (0 to 26) days, P = 0.36) and median (IQR) hospital-free days (4 (0 to 22) days vs. 6 (0 to 23) days, P = 0.57). Adrenal insufficiency incidence was significantly higher in etomidate than ketamine group (86% vs. 48%, P <0.001). There was no significant difference between the two groups in intubation conditions. There was no significant difference in outcome between the etomidate and ketamine groups on prespecified subgroup analysis (trauma or sepsis patients). Conclusions: Our results do not provide evidence for contraindicating etomidate during emergency intubation in critically ill patients. However, ketamine can constitute a good alternative.