Changes in hemodynamic parameters with the use of etomidate versus ketamine induction in the emergency department
1Department of Emergency Medicine, the King Abdulaziz University, 80215 Jeddah, Saudi Arabia
2Faculty of Medicine, the King Abdulaziz University, 80215 Jeddah, Saudi Arabia
DOI: 10.22514/sv.2021.005 Vol.17,Issue 2,March 2021 pp.85-92
Published: 08 March 2021
Objectives: Etomidate is the sedative agent of choice during rapid sequence intubation (RSI) owing to its hemodynamic stability, rapid onset of action, and short duration of action. Nevertheless, ketamine is rapidly gaining popularity as an alternative agent, primarily because of its catecholamine-mediated effects. This feature has prompted clinicians to use ketamine for hemodynamically unstable patients. The aim of this study was to compare the percent change in hemodynamic parameters resulting from the use of etomidate versus ketamine during RSI in the emergency department.
Methods: This cross-sectional prospective observational study conducted at an academic emergency department included patients recruited from March 2018 through May 2019 on a convenience basis when the principal investigator was scheduled to work in the emergency department.
Results: Our study showed a percent reduction in all hemodynamic parameters with the use of ketamine: -13.14% in systolic blood pressure, -10.40% in diastolic blood pressure, -10.15% in mean arterial pressure, and -1.12% in heart rate. Moreover, the rate of ≥ 20% reduction in hemodynamic parameters with ketamine was 27.27% in systolic blood pressure, 18.18% in diastolic blood pressure, 18.18% in mean arterial pressure, and 27.27% in heart rate.
Conclusions: Although ketamine has a sympathomimetic effect, it may cause hemodynamic instability in select patients. Therefore, caution is advised when using ketamine routinely during RSI, especially in critically ill patients in the emergency department.
Rapid sequence induction and intubation; Ketamine; Etomidate; Hemodynamic response; Acute reduction in hemodynamic parameters; Catecholamine depletion
Abdullah Bakhsh,Maryam Alnashri,Fatimah Alawami,Rafal Aseel,Maha Almaghthawi,Ghaida Alrahaili,Anas Bifari,Hassan Algethami. Changes in hemodynamic parameters with the use of etomidate versus ketamine induction in the emergency department. Signa Vitae. 2021. 17(2);85-92.
 Dibble C. Rapid sequence induction in the emergency department by emergency medicine personnel. Emergency Medicine Journal. 2006; 23: 62- 64.
 Okubo M, Gibo K, Hagiwara Y, Nakayama Y, Hasegawa K. The effec-tiveness of rapid sequence intubation (RSI) versus non-RSI in emergency department: an analysis of multicenter prospective observational study. International Journal of Emergency Medicine. 2017; 10: 1.
 Reynolds SF, Heffner J. Airway management of the critically ill patient. Chest. 2005; 127: 1397-1412.
 Hampton JP. Rapid-sequence intubation and the role of the emergency department pharmacist. American Journal of Health-System Pharmacy. 2011; 68: 1320-1330.
 Scherzer D, Leder M, Tobias JD. Pro-con debate: etomidate or ketamine for rapid sequence intubation in pediatric patients. The Journal of Pediatric Pharmacology and Therapeutics. 2012; 17: 142-149.
 Smith DC, Bergen JM, Smithline H, Kirschner R. A trial of etomidate for rapid sequence intubation in the emergency department. The Journal of Emergency Medicine. 2000; 18: 13-16.
 Zed PJ, Abu-Laban RB, Harrison DW. Intubating conditions and hemodynamic effects of etomidate for rapid sequence intubation in the emergency department: an observational cohort study. Academic Emergency Medicine. 2006; 13: 378-383.
 Shah S, Chowdhury I, Bhargava A, Sabbharwal B. Comparison of hemodynamic effects of intravenous etomidate versus propofol during induction and intubation using entropy guided hypnosis levels. Journal of Anaesthesiology Clinical Pharmacology. 2015; 31: 180.
 Wong DHW, Jenkins LC. The cardiovascular effects of ketamine in hypotensive states. Canadian Anaesthetists’ Society Journal. 1975; 22: 339-348.
 Weiskopf R, Bogetz M, Roizen M, Reid I. Cardiovascular and metabolic sequelae of inducing anesthesia with ketamine or thiopental in hypov-olemic swine. Anesthesiology. 1984; 60: 214-219.
 Waxman K, Shoemaker WC, Lippmann M. Cardiovascular effects of anesthetic induction with ketamine. Anesthesia & Analgesia. 1980; 59: 355-358.
 Miller M, Kruit N, Heldreich C, Ware S, Habig K, Reid C, et al. Hemodynamic response after rapid sequence induction with ketamine in out-of-hospital patients at risk of shock as defined by the shock index. Annals of Emergency Medicine. 2016; 68: 181-188.e2.
 Jabre P, Combes X, Ricard-Hibon A, Mirat P, Cibien J, Bourzeix C, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicenter randomized controlled trial. Critical Care. 2009; 13: P405.
 Upchurch CP, Grijalva CG, Russ S, Collins SP, Semler MW, Rice TW, et al. Comparison of etomidate and ketamine for induction during rapid sequence intubation of adult trauma patients. Annals of Emergency Medicine. 2017; 69: 24-33.e2.
 Lippmann M, Appel PL, Mok MS, Shoemaker WC. Sequential cardiores-piratory patterns of anesthetic induction with ketamine in critically ill patients. Critical Care Medicine. 1983; 11: 730-734.
 Gelissen HPMM, Epema AH, Henning RH, Krijnen HJ, Hennis PJ, den Hertog A. Inotropic effects of propofol, thiopental, midazolam, etomi-date, and ketamine on isolated human atrial muscle. Anesthesiology. 1996; 84: 397-403.
 Morris C, Perris A, Klein J, Mahoney P. Anaesthesia in haemodynami-cally compromised emergency patients: does ketamine represent the best choice of induction agent? Anaesthesia. 2009; 64: 532-539.
 Shafi S, Gentilello L. Pre-hospital endotracheal intubation and positive pressure ventilation is associated with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the national trauma data bank. Journal of Trauma and Acute Care Surgery. 2005; 59: 1140-1147.
 Franklin C, Samuel J, Hu T. Life-threatening hypotension associated with emergency intubation and the initiation of mechanical ventilation. The American Journal of Emergency Medicine. 1994; 12: 425-428.
 Price B, Arthur AO, Brunko M, Frantz P, Dickson JO, Judge T, et al. Hemodynamic consequences of ketamine vs etomidate for endotracheal intubation in the air medical setting. The American Journal of Emergency Medicine. 2013; 31: 1124-1132.
 Ballow SL, Kaups KL, Anderson S, Chang M. A standardized rapid sequence intubation protocol facilitates airway management in critically injured patients. Journal of Trauma and Acute Care Surgery. 2012; 73: 1401-1405.
 Schwartz DA, Horwitz LD. Effects of ketamine on left ventricular performance. Survey of Anesthesiology. 1975; 194: 410-414.
 Traber DL, Wilson RD, Priano LL. Differentiation of the cardiovascular effects of CI-581. Anesthesia & Analgesia. 1968; 47: 769-778.
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