Lit Matters #2: Ketamine vs Etomidate, round 1

Rapid sequence intubation with ketamine or etomidate produces similar first-pass success and mortality in critically ill adults. The main clinical distinction is peri-intubation hemodynamics: ketamine showed more short-term instability, while etomidate carries the longstanding concern of adrenal suppression and ongoing vasopressor exposure.

Ketamine Versus Etomidate for RSI

• Comparable intubation efficacy: First-pass success was similar with ketamine and etomidate, supporting either agent as a reasonable induction choice when the airway plan is sound.
• Hemodynamic instability signal: Ketamine was linked to more peri-intubation hemodynamic instability, a composite including hypotension, vasopressor use, and even arrest during the intubation window.
• Mortality and organ failure: Mortality and SOFA outcomes were not meaningfully different, which argues against a clear patient-centered superiority for either induction agent.
• Vasopressor exposure pattern: Ketamine may reduce vasopressor-free days, while etomidate is often viewed through the lens of post-intubation pressor needs and adrenal suppression. We get into that bedside tradeoff in the episode.
• Dose heterogeneity caveat: Etomidate dosing was relatively uniform at 0.2 to 0.3 mg/kg, while ketamine ranged widely from 0.5 to 2 mg/kg, an important wrinkle when applying the pooled results.
• Subgroup noninferiority theme: Shock, sepsis, trauma, prehospital intubation, and paralytic-use subgroups showed no clear winner, suggesting the ketamine-versus-etomidate debate is more nuanced than dogma implies.