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It’s the age-old question. We’ve read studies comparing propofol vs. etomidate, ketofol vs. etomidate, and now a meta-analysis about ketamine vs. etomidate. Etomidate is the staple induction agent for RSI, mostly used by Emergency Medicine, and to a degree in the Intensive Care Unit. However, the question about adrenal suppression was initiated in the early 2000s and researchers have been looking for other alternatives. This meta analysis attempted to look for another answer.
Settings: A meta-analysis of randomized controlled trials
Participants: 2384 patients who needed emergent intubation were included.
Outcome measurement: Peri-intubation instability
Study Results:
Compared with etomidate, ketamine was associated with higher risk of hemodynamic instability and moderate certainty (RR 1.29, 95% CI 1.07-1.57).
Ketamine was associated with lower risk of adrenal suppression, again, with moderate uncertainty (RR 0.54, 95% CI 0.45-0.66).
Ketamine was not associated with differences and risk of first successful intubation nor mortality.
Discussion:
Most studies were single center and involved small-moderate sample size, ranging from 20 patients to 700 patients.
For adrenal suppression, there were only 3 studies and a total of 1280 patients, thus, the results are still not definitive.
For an academic exercise, the Number Needed to Harm for both hemodynamic instability and adrenal suppression are calculated here.
Number Needed to Harm for hemodynamic instability: 25.
Number needed to harm for adrendal suppression: 11.
References
Greer A, Hewitt M, Khazaneh PT, Ergan B, Burry L, Semler MW, Rochwerg B, Sharif S. Ketamine Versus Etomidate for Rapid Sequence Intubation: A Systematic Review and Meta-Analysis of Randomized Trials