Key result
Etomidate compared with ketamine showed no significant difference in 30-day survival among critically ill patients undergoing rapid sequence intubation (RCTs: OR 0.92; 95% CI 0.68-1.24; P=0.58).
Why the study?
Etomidate is favored for hemodynamic stability during rapid sequence intubation, but concerns regarding adrenal insufficiency prompted evaluation of ketamine as an alternative induction agent.
Does etomidate compared to ketamine improve 30-day survival in critically ill patients undergoing in-hospital rapid sequence intubation?
Meta-Analysis (n=23,926)
Does etomidate compared to ketamine improve 30-day survival in critically ill patients undergoing in-hospital rapid sequence intubation?
Odds Ratio: 0.92 (95% CI 0.68–1.24)
p-value: p=0.58
Etomidate and ketamine show no significant difference in 30-day survival for in-hospital rapid sequence intubation, though etomidate increases adrenal insufficiency risk and ketamine increases post-intubation vasopressor requirements.
Comparable 30-day survival supports either agent for in-hospital RSI; leaves open subgroup effects and long-term outcomes.
Rapid sequence intubation (RSI) is a critical procedure in emergency and intensive care settings. Etomidate has been favored for its hemodynamic stability; however, concerns about adrenal insufficiency have prompted interest in ketamine as an alternative induction agent. This systematic review and meta-analysis aimed to compare the effects of etomidate vs ketamine on 30-day survival and other clinical outcomes in critically ill patients undergoing in-hospital RSI. A comprehensive literature search was conducted until 1 November 2024, across PubMed, Embase, Web of Science, Cochrane databases, and clinical trial registries. Eligible studies included randomized controlled trials (RCTs) and controlled clinical trials (CCTs) assessing etomidate vs ketamine for RSI. The primary outcome was 30-day survival. Secondary outcomes encompassed intubation difficulty, post-intubation vasopressor use, cardiovascular collapse, Sequential Organ Failure Assessment score, systemic steroid use, organ support-free days, and adrenal insufficiency. Fourteen studies comprising 23 926 patients (19 288 receiving etomidate; 4638 receiving ketamine) met the inclusion criteria. Pooled analyses of RCTs and CCTs revealed no significant difference in 30-day survival between the two agents [RCTs: odds ratio (OR) = 0.92, 95% confidence interval (CI): 0.68-1.24, P = 0.58; CCTs: OR = 1.16, 95% CI: 0.92-1.45, P = 0.58]. Ketamine was associated with a higher requirement for post-intubation vasopressor support (OR = 0.71, 95% CI: 0.53-0.96, P = 0.03) and an increase in ICU-free days. Etomidate use correlated with a significantly higher incidence of adrenal insufficiency (OR = 2.43, 95% CI: 1.67-3.53, P < 0.001). No significant differences were observed in intubation difficulty, cardiovascular collapse, or systemic steroid use between the groups. Ketamine and etomidate showed no significant difference in 30-day survival among critically ill patients undergoing RSI. However, etomidate was associated with a higher incidence of adrenal insufficiency, while ketamine required more post-intubation vasopressor support. Provenance and peer review: Not commissioned, externally peer-reviewed.
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Daghmouri et al. (2025) conducted a meta-analysis in critically ill patients undergoing in-hospital rapid sequence intubation (n=23,926). Etomidate vs. Ketamine was evaluated on 30-day survival (OR 0.92, 95% CI 0.68-1.24, p=0.58). Etomidate compared with ketamine showed no significant difference in 30-day survival among critically ill patients undergoing rapid sequence intubation (RCTs: OR 0.92; 95% CI 0.68-1.24; P=0.58).
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