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

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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.

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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. – PowerPoint PPT presentation

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


1
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

2
Aims
  1. Present critical appraisal of a recent Lancet
    publication of a randomised controlled trial
    comparing etomidate to ketamine in critically ill
    patients.
  2. Put results into context of Scottish intensive
    care practice.

3
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.

4
SOFA Score
Full Text Image
5
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.

6
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

7
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?

8
Results
9
Results
10
Results
11
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.

12
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.

13
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.

14
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