Readdressing rapid sequence induction and intubation using ketamine or etomidate: A systematic review and meta-analysis of randomized clinical trials.

Background: The objective of this article is to clinically compare the inducing drugs ketamine and etomidate during the orotracheal intubation procedure in critically ill patients, aiming to reduce early mortality and other important complications involved in this act.

Methods: This study is compliant to the PRISMA guidelines for systematic review and meta-analysis. A sensitive search was conducted using the databases PubMed (MEDLINE), Scopus, Lilacs (BVS), and Cochrane Library (Central). Our protocol included only randomized clinical trials, from the inception of the databases up to June 2024. Studies were selected if they compared ketamine to etomidate specifically for rapid sequence induction and intubation in critically ill patients. The outcomes assessed were: (1) all-cause mortality; (2) post-intubation arterial hypotension; (3) use of vasoactive drugs post-intubation; and (4) the incidence of adrenal insufficiency in the patient groups.

Results: With the sensitive search strategy in question, we have identified 956 studies. Among these, 10 randomized clinical trials met the inclusion criteria, collectively involving a total of 2862 patients. Ketamine demonstrated comparable effectiveness to etomidate in preventing all-cause mortality (odds ratio [OR] = 0.8; 95% confidence interval [CI]: 0.65-1.21; P = .06). The rates of arterial hypotension post-intubation were also similar between the groups (OR = 1.28; 95% CI: 0.96-1.7; P = .34) and the same could be found when comparing the use of vasoactive drugs post-intubation (OR = 0.68; 95% CI: 0.36-1.27; P = .001). However, ketamine was less associated with adrenal insufficiency (OR = 0.35; 95% CI: 0.15-0.86; P = .008).

Conclusions: Ketamine and etomidate demonstrated comparable effectiveness for rapid sequence intubation in terms of mortality and post-intubation hypotension. However, ketamine was associated with a lower risk of adrenal insufficiency, suggesting it may be a preferable option when patients are at high risk for adrenal suppression.