Daghmouri Mohamed Aziz, Chaouch Mohamed Ali, Noomen Mohamed, Chaabene Wael, Deniau Benjamin, Barnes Ellington, Mion Georges, Cheurfa Cherifa, Gafsi Besma, Camby Matthieu
Department of Anesthesia, Center for Intercommunal Hospitals of Montreuil, Montreuil, France.
Department of Visceral Surgery.
Eur J Emerg Med. 2025 Jun 1;32(3):160-170. doi: 10.1097/MEJ.0000000000001237. Epub 2025 Apr 14.
Rapid sequence intubation (RSI) is a critical procedure in emergency and intensive care settings. Etomidate has been favored for its hemodynamic stability; however, concerns about adrenal insufficiency have prompted interest in ketamine as an alternative induction agent. This systematic review and meta-analysis aimed to compare the effects of etomidate vs ketamine on 30-day survival and other clinical outcomes in critically ill patients undergoing in-hospital RSI. A comprehensive literature search was conducted until 1 November 2024, across PubMed, Embase, Web of Science, Cochrane databases, and clinical trial registries. Eligible studies included randomized controlled trials (RCTs) and controlled clinical trials (CCTs) assessing etomidate vs ketamine for RSI. The primary outcome was 30-day survival. Secondary outcomes encompassed intubation difficulty, post-intubation vasopressor use, cardiovascular collapse, Sequential Organ Failure Assessment score, systemic steroid use, organ support-free days, and adrenal insufficiency. Fourteen studies comprising 23 926 patients (19 288 receiving etomidate; 4638 receiving ketamine) met the inclusion criteria. Pooled analyses of RCTs and CCTs revealed no significant difference in 30-day survival between the two agents [RCTs: odds ratio (OR) = 0.92, 95% confidence interval (CI): 0.68-1.24, P = 0.58; CCTs: OR = 1.16, 95% CI: 0.92-1.45, P = 0.58]. Ketamine was associated with a higher requirement for post-intubation vasopressor support (OR = 0.71, 95% CI: 0.53-0.96, P = 0.03) and an increase in ICU-free days. Etomidate use correlated with a significantly higher incidence of adrenal insufficiency (OR = 2.43, 95% CI: 1.67-3.53, P < 0.001). No significant differences were observed in intubation difficulty, cardiovascular collapse, or systemic steroid use between the groups. Ketamine and etomidate showed no significant difference in 30-day survival among critically ill patients undergoing RSI. However, etomidate was associated with a higher incidence of adrenal insufficiency, while ketamine required more post-intubation vasopressor support. Provenance and peer review: Not commissioned, externally peer-reviewed.
快速顺序诱导插管（RSI）是急诊和重症监护环境中的一项关键操作。依托咪酯因其血流动力学稳定性而受到青睐；然而，对肾上腺功能不全的担忧促使人们对氯胺酮作为替代诱导剂产生兴趣。本系统评价和荟萃分析旨在比较依托咪酯与氯胺酮对接受院内RSI的重症患者30天生存率和其他临床结局的影响。截至2024年11月1日，在PubMed、Embase、Web of Science、Cochrane数据库和临床试验注册库中进行了全面的文献检索。符合条件的研究包括评估依托咪酯与氯胺酮用于RSI的随机对照试验（RCT）和对照临床试验（CCT）。主要结局是30天生存率。次要结局包括插管困难、插管后血管升压药使用、心血管衰竭、序贯器官衰竭评估评分、全身类固醇使用、无器官支持天数和肾上腺功能不全。14项研究共纳入23926例患者（19288例接受依托咪酯；4638例接受氯胺酮）符合纳入标准。对RCT和CCT的汇总分析显示，两种药物在30天生存率方面无显著差异[RCT：优势比（OR）=0.92，95%置信区间（CI）：0.68-1.24，P=0.58；CCT：OR=1.16，95%CI：0.92-1.45，P=0.58]。氯胺酮与插管后更高的血管升压药支持需求相关（OR=0.71，95%CI：0.53-0.96，P=0.03），且无ICU天数增加。依托咪酯的使用与肾上腺功能不全的发生率显著升高相关（OR=2.43，95%CI：1.67-3.53，P<0.001）。两组在插管困难、心血管衰竭或全身类固醇使用方面未观察到显著差异。在接受RSI的重症患者中，氯胺酮和依托咪酯在30天生存率方面无显著差异。然而，依托咪酯与更高的肾上腺功能不全发生率相关，而氯胺酮需要更多的插管后血管升压药支持。来源和同行评审：非委托研究，外部同行评审。
