Contributor: Ricky Dhaliwal MD
Educational Pearls:
Etomidate was previously the drug of choice for rapid sequence intubation (RSI)
However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity
A recent meta-analysis analyzing etomidate as an induction agent showed the following:
11 randomized-controlled trials with 2704 patients
Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death
The probability of any mortality increase was 98.1%
Ketamine is preferable due to a better adverse effect profile
Laryngeal spasms and bronchorrhea are the most common adverse effects after IV push
Beneficial effects on hemodynamics via catecholamine surge, albeit not as pronounced in shock patients
2023 meta-analysis compared ketamine and etomidate for RSI
Ketamine's probability of reducing mortality is cited as 83.2%
Overall, induction with ketamine demonstrates a reduced risk of mortality compared with etomidate
The dosage of each medication for induction
Etomidate: 20 mg based on 0.3 mg/kg for a 70 kg adult
Ketamine: 1-2 mg/kg (or 0.5-1 mg/kg in patients with shock)
Patients with asthma and/or COPD also benefit from ketamine induction due to putative bronchodilatory properties
References
Goyal S, Agrawal A. Ketamine in status asthmaticus: A review. Indian J Crit Care Med. 2013;17(3):154-161. doi:10.4103/0972-5229.117048
Koroki T, Kotani Y, Yaguchi T, et al. Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care. 2024;28(1):1-9. doi:10.1186/s13054-024-04831-4
Kotani Y, Piersanti G, Maiucci G, et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. J Crit Care. 2023;77(April 2023):154317. doi:10.1016/j.jcrc.2023.154317
Summarized & Edited by Jorge Chalit, OMS3
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