Doctors treating critically ill patients in emergency settings may benefit from using the sedative etomidate instead of ketamine during tracheal intubation. This recommendation follows a groundbreaking randomized trial published on December 9 in the New England Journal of Medicine. The study, known as the Randomized Trial of Sedative Choice for Intubation (RSI), is the first multicenter trial to highlight the cardiovascular risks associated with high doses of ketamine, such as low blood pressure and arrhythmia.
The trial, led by Dr. Jonathan Casey of Vanderbilt University Medical Center, alongside Dr. Brian Driver and Dr. Matthew Prekker from Hennepin Healthcare, involved 2,365 patients across 14 emergency departments and intensive care units in the United States. It concluded that etomidate is not only safe but also significantly reduces the risk of dangerously low blood pressures during intubation compared to ketamine.
Understanding the Risks and Benefits
Dr. Casey emphasized the importance of such studies, stating, “We know that patients receive treatments every day in hospitals around the world that have never been evaluated in a rigorous study and may be ineffective or even harmful.” He added, “Studies like RSI are critically important to understand the treatments that patients are already receiving and to ensure that patients receive the treatments that will result in the best outcomes.”
Dr. Driver further explained the significance of the findings: “Ketamine and etomidate have both been around for decades and are used countless times each year during emergency intubations. Despite their widespread use, no large, multi-center trial had ever directly compared the two to determine which medication leads to better outcomes for patients until the RSI trial.”
“Our results show that etomidate is a safe option and that ketamine, in some situations, can trigger significant drops in blood pressure during intubation,” said Dr. Driver.
Historical Context and Shifts in Medical Practice
Historically, etomidate was the preferred sedative due to its effectiveness. However, concerns arose when it was found to impair cortisol production, potentially increasing the risk of death post-intubation. These concerns led some countries to remove etomidate from the market, prompting a shift towards ketamine as the primary sedative during emergency tracheal intubations.
Ketamine’s popularity has surged in recent years, not only for intubation but also for treating conditions such as acute and chronic pain, depression, and post-traumatic stress disorder. Despite its widespread use, data on ketamine’s effectiveness and safety remain limited.
Implications and Future Research
The results of the RSI trial may influence countries that had previously banned etomidate to reconsider its availability. The study was presented at the Critical Care Reviews conference in Melbourne, Australia, coinciding with the journal publication. Australia is one of the countries where etomidate had been removed from the market.
Looking ahead, researchers are exploring the long-term effects of sedative medications on patient-centered outcomes, such as symptoms of post-traumatic stress disorder at 12 months. Additionally, Hennepin Healthcare is spearheading a large, multicenter randomized trial called BREATHE. This study aims to determine whether using a smaller size of breathing tube can prevent injury to patients’ vocal cords and long-term issues with breathing, speaking, and swallowing.
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).
The findings from the RSI trial underscore the need for continuous evaluation of medical practices to ensure patient safety and optimal outcomes. As more data becomes available, medical professionals can make informed decisions that enhance patient care and safety in emergency settings.
