Efficacy of ketamine versus etomidate for rapid sequence intubation, among critically ill patients in terms of mortality and success rate: A systematic review and meta-analysis of randomized controlled trials.

Introduction: Etomidate as well as ketamine are hemodynamically stable induction agents for rapid sequence intubation (RSI) in critically ill patients. Despite, their relative stability in terms of hemodynamics, the impact of choice of agent, on mortality and success of the procedure, is debatable and has not yet been explored via systematic review and meta-analysis.

Aim and objective: The objective of this systematic review is to compare the efficacy of ketamine versus etomidate for RSI in terms of mortality, hemodynamic parameters, and success rate.

Methodology: A comprehensive search was conducted throughout PubMed, Embase, and Web of Science from starting date of database until April 2024. Randomized controlled trials, comparing safety and efficacy of ketamine against etomidate as induction drugs for critically ill patients undergoing RSI were included. Primary outcome was risk of 28-day mortality, while secondary outcome included success rate, and post-induction hypotension. Pooled relative-risks (RR) with 95% confidence intervals (CI) were calculated using random-effects meta-analysis.

Results: Four studies (n= 1663) were meta-analyzed. There was no statistically significant difference between the two drugs for: 28-day mortality RR 0.95 (95% CI: 0.72-1.25), (heterogeneity- I2 39%, level of certainty of evidence per GRADE: moderate); first pass success rate 1.00, (0.97- 1.03); post induction cardiac arrest 1.10 (0.62- 1.96). Post induction hypotension was higher in the ketamine group 1.30 (1.03- 1.64), although result was not statistically significant.

Conclusion: There is no difference in mortality outcomes for ketamine vs etomidate, when used for RSI in critically ill patients. ketamine, however, is associated with higher risk of post induction hypotension.