Ketamine versus Etomidate as an induction agent for tracheal intubation: An updated meta-analysis of randomized clinical trials.

Background

Emergency tracheal intubation is a critical and life-saving intervention. However, the selection between ketamine and etomidate as induction agents for emergency tracheal intubation remains controversial. This updated systematic review and meta-analysis aims to compare ketamine and etomidate as induction agents for rapid sequence intubation in critically ill patients.

Methods

Five electronic databases were searched for randomized clinical trials (RCTs) evaluating ketamine and etomidate in critically ill patients. Observational studies were excluded. The primary outcome was mortality at the longest follow-up. The dichotomous outcomes were reported as risk ratios (RRs), and continuous outcomes as mean differences (MDs) with 95% confidence intervals (CI).

Results

Eight studies, enrolling 4,807 patients, were included. Ketamine and etomidate showed no significant difference in mortality (RR: 0.97, 95% CI: 0.89-1.06, p =  0.51). Additionally, survival was similar between ketamine and etomidate across both time points (24 h and 7 d). However, ketamine was associated with a significantly higher risk of post-induction cardiovascular collapse (RR: 1.34, 95% CI: 1.16-1.54, p <  0.01).

Conclusion

Neither ketamine nor etomidate conferred a survival advantage in critically ill patients. However, ketamine was associated with a higher risk of post-induction cardiovascular collapse based on a pooled analysis of two open-label trials, whereas etomidate was associated with a higher risk of adrenal insufficiency. The certainty of the evidence for cardiovascular collapse is limited by the small number of studies, the open-label design, and heterogeneity in the outcome definitions. REGISTRATION PROSPERO (CRD420261361259).