Intubation For Emergency Airway Control In Critically Ill Patients Is Safer With Ketamine As A Sedative

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Main Category: Clinical Trials / Drug Trials
Article Date: 01 Jul 2009 - 0:00 PDT

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An article published Online First and in a future edition of The Lancet reports on the use of Ketamine as a safe and valuable substitute to conventional etomidate. It is used as a sedative during intubation. Critically ill patients frequently require tubing inserted into their airways to help control their breathing during treatment. The article is the work of Professor Frederic Adnet, SAMU 93, of the Hôpitaux de Paris, France, and his team.

There is evidence from prior studies that etomidate could be connected with increased mortality in patients with sepsis (blood stream infection). 655 patients were enrolled in this randomised controlled trial from twelve emergency departments and sixty five intensive care units in France. They all needed emergency intubation. 328 patients received 0.3 mg/kg etomidate and 327 patients received 2mg/kg ketamine. The endpoint of the trial was the maximum score of the sequential organ failure assessment (SOFA is a scoring system for assessment of in-hospital morbidity). Patients who died before reaching hospital or were discharged from intensive care within three days were excluded.

In total, 234 patients were analysed in the etomidate groups and 235 in the ketamine group. The average maximum SOFA score did not vary considerably between the two groups with 10.3 for the etomidate group, and 9.6 for the ketamine group. Also there was no significant difference in the difficulty of intubation between groups. However, adrenal insufficiency was reported in 86 percent of patients given etomidate, compared with just 48 percent of those given ketamine. Adrenal insufficiency is an acknowledged side effect of etomidate use. It is a condition in which the adrenal glands do not produce adequate amounts of steroid hormones which are chemicals produced by the body that regulate organ function. Adrenal insufficiency is probably associated with increased mortality in critically ill patients, although the reason for this has never been established. The authors mention that the cause for lower adrenal insufficiency in the ketamine group is probably related to other factors than just the sedative agent used.

The authors write in conclusion: "Our results show that ketamine is a safe and valuable alternative to etomidate for endotracheal intubation in critically ill patients, and should be considered in those with sepsis."

In a related note, Dr Volker Wenzel and Dr Karl H Lindner, from the Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Austria, write: "In view of today's data, we might have to consider whether successful emergency intubation of critically ill patients depends not only on manual skills and clinical experience but also on pharmacological knowledge."

Drs. Wenzel and Lindner remark that the stricter policies of the European Government hold back studies of a non-commercial pathology such as multiple trauma, the number one cause of death in young adults. They write: "Our fate would be similar to physicians in developing countries, who have many questions about optimising health care but cannot do clinical trials to find valid answers."

"Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial"
Patricia Jabre, Xavier Combes, Frederic Lapostolle, Mohamed Dhaouadi, Agnes Ricard-Hibon, Benoit Vivien, Lionel Bertrand, Alexandra Beltramini, Pascale Gamand, Stephane Albizzati, Deborah Perdrizet, Gaelle Lebail, Charlotte Chollet-Xemard, Virginie Maxime, Christian Brun-Buisson, Jean-Yves Lefrant, Pierre-Edouard Bollaert, Bruno Megarbane, Jean-Damien Ricard, Nadia Anguel, Eric Vicaut, Frederic Adnet, on behalf of the KETASED Collaborative Study Group
DOI: 10.1016/S0140-6736(09)60949-1
thelancet

Written by Stephanie Brunner (B.A.)
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