Abstract Background Etomidate, ketamine, and propofol are all used as induction agents for emergency tracheal intubation in critically ill adults but it remains uncertain which agent should be preferable. Methods We searched MEDLINE and Embase (inception to December 2025) for randomized controlled trials comparing etomidate, ketamine, propofol, or ketamine–propofol combination (ketofol) for emergency or rapid sequence intubation in critically ill adults. We performed random-effects network meta-analysis using the frequentist framework. The primary outcome was short-term mortality (28–30 day, or ICU/in-hospital mortality when unavailable). Secondary outcomes included cardiovascular collapse, post-induction hypotension, vasopressor use, first-pass intubation success, and peri-intubation cardiac arrest. Certainty of evidence was assessed using the CINeMA framework. Results Nine trials (4, 672 patients, four treatments) were included. Ketamine and etomidate probably result in similar mortality (OR 0. 96, 95% CI 0. 80–1. 16; I^2 = 30%; moderate certainty). Evidence for other mortality comparisons was very uncertain: ketamine vs propofol (OR 1. 53, 0. 80–2. 93; 1 trial; low certainty) and etomidate vs propofol (OR 0. 63, 0. 32–1. 24; indirect only; very low certainty). Compared with etomidate, ketamine probably increases cardiovascular collapse (OR 1. 44, 1. 20–1. 71; moderate certainty) and may increase post-induction hypotension (OR 1. 34, 1. 07–1. 68; low certainty) and peri-intubation vasopressor use (OR 1. 45, 1. 21–1. 74; low certainty). There was probably little or no difference in first-pass intubation success or cardiac arrest. Conclusions Etomidate and ketamine probably result in similar mortality, but confidence intervals are compatible with clinically important differences in either direction—ketamine probably causes more peri-intubation hemodynamic instability. Beyond one trial, no randomized evidence exists for propofol in emergency intubation of critically ill adults.
Zampieri et al. (Tue,) studied this question.