Critically ill patients often need tubing inserted into their airways to help control their breathing during treatment. Ketamine is a safe and valuable alternative to conventional etomidate to use as a sedative to during this intubation. This is among the conclusions of an Article published Online First and in an upcoming edition of The Lancet, written by Professor Frederic Adnet, SAMU 93, Hôpitaux de Paris, France, and colleagues.
Previous studies have suggested that etomidate could be associated with increased mortality in patients with sepsis. In this randomised controlled trial, 655 patients who needed emergency intubation were enrolled from 12 emergency departments and 65 intensive care units in France. Patients received either 0.3 mg/kg etomidate (328 patients) or 2mg/kg ketamine (327). The endpoint of the trial was the maximum score of the sequential organ failure assessment (SOFA- a scoring system for assessment of in-hospital morbidity). Patients who died before reaching hospital or discharged from intensive care within 3 days were excluded.
A total of 234 patients were analysed in the etomidate groups and 235 in the ketamine group. The mean maximum SOFA score did not differ significantly between the two groups (10.3 for etomidate, 9.6 for ketamine). The difficulty of intubation also did not differ significantly between groups. However, adrenal insufficiency*-a known side effect of etomidate use—occurred in 86% of patients given etomidate, compared with just 48% of those given ketamine. The authors say that the reason adrenal insufficiency occurred in the ketamine group at all is because it is probably related to other causes than just the sedative agent used.
The authors conclude: "Our results show that ketamine is a safe and valuable alternative to etomidate for endotracheal intubation in critically ill patients, and should be considered in those with sepsis."
In an accompanying Comment, Dr Volker Wenzel and Dr Karl H Lindner, Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Austria, say: "In view of today's data, we might have to consider whether successful emergency intubation of critically ill patients depends not only on manual skills and clinical experience but also on pharmacological knowledge."
Drs. Wenzel and Lindner add that tightening regulations of the European Government impede studies of commercially non-interesting pathology such as multiple trauma, the number one killer of young adults. They say: "Our fate would be similar to physicians in developing countries, who have many questions about optimising health care but cannot do clinical trials to find valid answers."
Professor Frederic Adnet, SAMU 93, Hôpitaux de Paris, France T) +33 6 64 23 88 61 E) Frederic.adnet@avc.aphp.fr
Dr Volker Wenzel, Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Austria T) +43 512 504-80430 / +43 676 9034266 E) volker.wenzel@uki.at
For full Article and Comment: http://press.thelancet.com/ketfinal.pdf
Note to editors: *Adrenal insufficiency is is a condition in which the adrenal glands, located above the kidneys, do not produce adequate amounts of steroid hormones (chemicals produced by the body that regulate organ function). Adrenal insufficiency can also occur when the hypothalamus or the pituitary gland, both located at the base of the skull, doesn't make adequate amounts of the hormones that assist in regulating adrenal function. Adrenal insufficiency is probably associated with increased mortaility in critically ill patients, although the reason for this has never been established.
Journal
The Lancet