Intubations are a common medical practice in which doctors insert a tube into the trachea to hold the airway open for patients who cannot breathe effectively due to illness or trauma-related injuries. Results in a recent multisite trial, in which the University of Alabama at Birmingham was a trial site, revealed doctors may want to consider utilizing etomidate, rather than ketamine, during intubation procedures.
The “Randomized Trial of Sedative Choice for Intubation” study, published in the New England Journal of Medicine, observed two medications that are most commonly used for sedation with intubations: ketamine and etomidate. The goal was to determine which drug is best to use during intubations. Results revealed etomidate causes less hypotension than ketamine and does not increase risk of death in patients who have been intubated.
RSI is the first multicenter trial to demonstrate significant cardiovascular risks of high doses of ketamine (low blood pressure, arrhythmia), side effects that have not been well studied in the past.
Derek Russell, M.D., associate professor in the Division of Pulmonary, Allergy and Critical Care Medicine, served as the site principal investigator at UAB.
The study, led by Jonathan Casey, M.D., associate professor of medicine in the Division of Allergy, Pulmonary and Critical Care Medicine at Vanderbilt University Medical Center, amounted a team of patients, clinicians and researchers from six cities across the United States.
The RSI trial compared the use of ketamine and etomidate during tracheal intubation of 2,365 patients in 14 emergency departments and intensive care units in the United States. The trial found that etomidate is safe to use, meaning it did not increase the risk of death, and that etomidate significantly decreased the risk of dangerously low blood pressures during the procedure, compared with ketamine.
“It’s fair to say both drugs are equally safe,” Russell said. “However, we learned a lot about their side effect profiles that will help us use them more safely in emergency care.”
Historically, etomidate was the more commonly used sedative; but it was found to impair production of cortisol, which raised concerns that it could increase the risk of death following intubation. Based on these concerns, some countries removed etomidate from the market.
In many settings, ketamine replaced etomidate as the primary sedative during emergency tracheal intubation. This has been part of a movement by clinicians and patients to use ketamine for an increasing number of problems, including acute and chronic pain, depression, and post-traumatic stress disorder, despite limited data on its effectiveness and safety.
For next steps, site researchers are evaluating the effect of sedative medications on long-term patient-centered outcomes like symptoms of post-traumatic stress disorder at 12 months.
The RSI trial was funded by the Patient-Centered Outcomes Research Institute (award number BPS-2022C3-30021) and the National Institutes of Health (award number K23HL153584).