60-Second Journal Club: Randomized Trial of Sedative Choice for Intubation

Why It Matters

The trial shows no mortality advantage for ketamine over etomidate, allowing clinicians to prioritize hemodynamic stability when selecting induction agents for emergency intubation.

Key Takeaways

• Ketamine and etomidate show similar 28‑day mortality rates.
• Study enrolled 2,000 critically ill adults across 14 US sites.
• Ketamine linked to slightly higher cardiovascular complications during intubation.
• No significant mortality benefit found for ketamine over etomidate.
• Findings challenge assumptions about etomidate’s cortisol suppression risk.

Summary

The video reviews a multicenter, unblinded randomized trial that compared ketamine with etomidate as induction agents for emergency tracheal intubation in critically ill adults. Conducted across 14 emergency departments and intensive care units in the United States, the study enrolled 2,000 patients, allocating them equally to receive either ketamine or etomidate.

The primary endpoint was all‑cause in‑hospital mortality by day 28. Mortality was 28.1% in the ketamine arm versus 29.1% in the etomidate arm, a difference that did not reach statistical significance. However, the trial observed a modest increase in cardiovascular complications—such as hypotension and arrhythmias—among patients receiving ketamine during the intubation procedure.

Investigators highlighted that the trial’s unblinded design could influence provider behavior, yet the large sample size and diverse settings bolster the robustness of the findings. The lack of a mortality advantage for ketamine suggests that concerns over etomidate‑induced adrenal suppression may be less clinically consequential than previously thought.

For clinicians, the results imply that the choice between ketamine and etomidate can be guided by individual patient hemodynamics rather than an expectation of survival benefit. The data also prompt re‑evaluation of guidelines that favor etomidate solely to avoid cortisol suppression, emphasizing a more nuanced, patient‑centered approach to induction medication selection.

Original Description

Induction medication for emergency intubation — does the choice matter? NEJM Editorial Fellow Katerina Lin, MD, explains a randomized trial to determine the effects of ketamine vs. etomidate for induction of anesthesia during emergency tracheal intubation. Full RSI trial results at NEJM.org.

#pulmonology #criticalcare #nejm