Kotani Yuki, Russotto Vincenzo
Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan.
Department of Anesthesia and Critical Care, AOU S. Luigi Gonzaga, Orbassano, Turin, Italy.
Crit Care Med. 2025 Jan 1;53(1):e173-e181. doi: 10.1097/CCM.0000000000006506. Epub 2024 Nov 22.
Concise definitive review of the use of induction agents in critically ill patients undergoing tracheal intubation and their association with outcomes.
Original publications were retrieved through a PubMed search with search terms related to induction agents for tracheal intubation in critically ill patients.
We included randomized controlled trials and observational studies that reported patient outcomes.
Data from included studies, including choice of induction agents and clinically relevant outcomes, were extracted.
Etomidate and ketamine have been the most studied induction agents in critical care during last years. Recent studies on etomidate investigated the clinical impact of its recognized adrenal suppression in terms of morbidity and mortality. Etomidate may carry a non-negligible mortality risk without definitive hemodynamic benefits compared with ketamine. Available data then support the use of ketamine over etomidate, since the difference in the hemodynamic profile seems to be of minor clinical relevance. No multicenter randomized studies are available comparing propofol to other induction agents but evidence from a large observational study identified an association of propofol with post-intubation cardiovascular instability in critically ill patients. Despite the observational nature of these findings cannot exclude the role of confounders, the association of propofol with post-induction cardiovascular instability is pharmacologically plausible, justifying its avoidance in favor of drugs with a better safety profile in critical care such as ketamine.
Although no definitive conclusions can be drawn based on the available evidence, recent evidence pointed out the potential negative effect of etomidate on survival and the association of propofol with cardiovascular instability. Ketamine may be considered the drug with a safer profile, widespread availability and low cost but future research should provide definitive data on optimal drug selection, its dosage in the context of critical illness and concomitant interventions to minimize the risk of peri-intubation complications.
对危重症患者气管插管时诱导药物的使用及其与预后的关系进行简明的确定性综述。
通过PubMed检索，使用与危重症患者气管插管诱导药物相关的检索词获取原始出版物。
我们纳入了报告患者预后的随机对照试验和观察性研究。
提取纳入研究的数据，包括诱导药物的选择和临床相关预后。
依托咪酯和氯胺酮是近年来重症监护中研究最多的诱导药物。最近关于依托咪酯的研究调查了其公认的肾上腺抑制在发病率和死亡率方面的临床影响。与氯胺酮相比，依托咪酯可能带来不可忽视的死亡风险，且无明确的血流动力学益处。现有数据支持在氯胺酮与依托咪酯之间优先选择氯胺酮，因为血流动力学特征的差异似乎临床相关性较小。目前尚无多中心随机研究比较丙泊酚与其他诱导药物，但一项大型观察性研究的证据表明，丙泊酚与危重症患者插管后心血管不稳定有关。尽管这些研究结果的观察性质不能排除混杂因素的作用，但丙泊酚与诱导后心血管不稳定的关联在药理学上是合理的，这证明在重症监护中应避免使用丙泊酚，而选择安全性更好的药物，如氯胺酮。
尽管根据现有证据无法得出明确结论，但最近的证据指出了依托咪酯对生存的潜在负面影响以及丙泊酚与心血管不稳定的关联。氯胺酮可被视为安全性更高、广泛可用且成本低廉的药物，但未来的研究应提供关于最佳药物选择、其在危重症情况下的剂量以及伴随干预措施的确切数据，以尽量减少插管周围并发症的风险。
