Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre rando

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Etomidate versus ketamine for rapid sequence
intubation in acutely ill patients a multicentre
randomised controlled trial. Jabre et al. Lancet
2009 374 293-300.

• Critically Appraised Topic
• Chris Hawthorne ST4 Anaesthetics
• Stirling Royal Infirmary
• September 2009

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Aims

• Present critical appraisal of a recent Lancet
  publication of a randomised controlled trial
  comparing etomidate to ketamine in critically ill
  patients.
• Put results into context of Scottish intensive
  care practice.

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Background

• French study.
• Structure of French emergency medical services is
  different to that in the UK.
• The emergency medical services are ambulance base
  stations equipped with mobile intensive care
  units led by a senior physician.
• Etomidate is the sedative-hypnotic drug that is
  most often used for rapid sequence intubation in
  this context.
• Etomidate can cause reversible adrenal
  insufficiency and may be associated with
  increased morbidity in critically ill patients.
• A possible alternative to etomidate is ketamine,
  which is not known to inhibit the adrenal axis.

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SOFA Score
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Methods

• Patient Selection over 18 years old and needing
  sedation for emergency intubation by emergency
  medical service.
• Randomisation computerised random number
  generator.
• Treatment Groups
• Control Etomidate 0.3mg/kg with suxamethonium
  1mg/kg
• Study Ketamine 2mg/kg with suxamethonium 1mg/kg
• Patients transferred to 1 of 65 ICUs for ongoing
  care.
• Does control group represent best practice?
• Blinding the emergency physician was aware of
  assignment but ICU staff were masked to treatment
  assigned.

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Methods

• End Points
• Primary maximum SOFA (sequential organ failure
  assessment) score during the first 3 days in the
  intensive care unit.
• Secondary ?-SOFA score, 28-day all-cause
  mortality, days free from ICU and organ support
  free days.
• How valid is the SOFA score as a surrogate marker
  of morbidity to compare the effect of etomidate
  versus ketamine?
• Analysis
• Modified intention to treat

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Trial Profile

• Of 655 randomised patients, only 469 were used
  for analysis.
• Was it appropriate to exclude patients who were
  discharged early or died before reaching hospital?

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Results
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Results
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Results
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Trial Conclusions

• Our study shows that one etomidate bolus is not
  associated with a significant increase in
  morbidity or mortality compared with ketamine in
  patients admitted to the intensive care unit.
• In conclusion, our results show that ketamine is
  a safe and valuable alternative to etomidate for
  intubation in critically ill patients,
  particularly in septic patients.

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Applicability

• Study relates to rapid sequence intubation
  performed by emergency medical services not
  within ICU.
• Patient population is unselected critically ill
  patients likely to relate to UK ICU practice.
• Etomidate would be unlikely to feature in the
  control arm of a UK ICU trial.

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Bottom Line

• Flawed study
• not gold standard control group
• maximum SOFA score in 72 hours is a questionable
  primary end point
• many patients excluded from analysis
• However, from this trial it would seem reasonable
  to choose ketamine over etomidate for rapid
  sequence intubation by emergency services no
  evidence of harm, avoid adrenal suppression.
• Unlikely to significantly influence UK ICU
  practice.

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