de Morais Lucas Bittar, Radel-Neto Guilherme Requião, Dos Santos Valsecchi Victor Alexandre, Costa Renan Alecsander, Hueb Whady
Universidade Anhembi Morumbi, São Paulo, Brazil.
Escola Paulista de Medicina, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil.
Medicine (Baltimore). 2025 May 9;104(19):e42207. doi: 10.1097/MD.0000000000042207.
The objective of this article is to clinically compare the inducing drugs ketamine and etomidate during the orotracheal intubation procedure in critically ill patients, aiming to reduce early mortality and other important complications involved in this act.
This study is compliant to the PRISMA guidelines for systematic review and meta-analysis. A sensitive search was conducted using the databases PubMed (MEDLINE), Scopus, Lilacs (BVS), and Cochrane Library (Central). Our protocol included only randomized clinical trials, from the inception of the databases up to June 2024. Studies were selected if they compared ketamine to etomidate specifically for rapid sequence induction and intubation in critically ill patients. The outcomes assessed were: (1) all-cause mortality; (2) post-intubation arterial hypotension; (3) use of vasoactive drugs post-intubation; and (4) the incidence of adrenal insufficiency in the patient groups.
With the sensitive search strategy in question, we have identified 956 studies. Among these, 10 randomized clinical trials met the inclusion criteria, collectively involving a total of 2862 patients. Ketamine demonstrated comparable effectiveness to etomidate in preventing all-cause mortality (odds ratio [OR] = 0.8; 95% confidence interval [CI]: 0.65-1.21; P = .06). The rates of arterial hypotension post-intubation were also similar between the groups (OR = 1.28; 95% CI: 0.96-1.7; P = .34) and the same could be found when comparing the use of vasoactive drugs post-intubation (OR = 0.68; 95% CI: 0.36-1.27; P = .001). However, ketamine was less associated with adrenal insufficiency (OR = 0.35; 95% CI: 0.15-0.86; P = .008).
Ketamine and etomidate demonstrated comparable effectiveness for rapid sequence intubation in terms of mortality and post-intubation hypotension. However, ketamine was associated with a lower risk of adrenal insufficiency, suggesting it may be a preferable option when patients are at high risk for adrenal suppression.
本文的目的是在重症患者的口气管插管过程中，对诱导药物氯胺酮和依托咪酯进行临床比较，旨在降低该操作相关的早期死亡率和其他重要并发症。
本研究符合系统评价和荟萃分析的PRISMA指南。使用数据库PubMed（MEDLINE）、Scopus、Lilacs（BVS）和Cochrane图书馆（Central）进行了全面检索。我们的方案仅纳入从数据库建立至2024年6月的随机临床试验。若研究专门比较了氯胺酮和依托咪酯在重症患者快速序贯诱导插管中的效果，则被纳入。评估的结局包括：（1）全因死亡率；（2）插管后动脉低血压；（3）插管后使用血管活性药物的情况；（4）患者组中肾上腺功能不全的发生率。
采用上述全面检索策略，我们共识别出956项研究。其中，10项随机临床试验符合纳入标准，共涉及2862例患者。氯胺酮在预防全因死亡率方面与依托咪酯效果相当（优势比[OR]=0.8；95%置信区间[CI]：0.65 - 1.21；P = 0.06）。两组插管后动脉低血压的发生率也相似（OR = 1.28；95% CI：0.96 - 1.7；P = 0.34），比较插管后使用血管活性药物的情况时也是如此（OR = 0.68；95% CI：0.36 - 1.27；P = 0.001）。然而，氯胺酮与肾上腺功能不全的相关性较低（OR = 0.35；95% CI：0.15 - 0.86；P = 0.008）。
在死亡率和插管后低血压方面，氯胺酮和依托咪酯在快速序贯插管中显示出相当的效果。然而，氯胺酮与肾上腺功能不全的风险较低相关，这表明当患者肾上腺抑制风险较高时，它可能是更优选择。
