Abstract
Purpose
Etomidate and ketamine are hemodynamically stable induction agents often used to sedate critically ill patients during emergency endotracheal intubation. In 2015, quality improvement data from our hospital suggested a survival benefit at Day 7 from avoidance of etomidate in critically ill patients during emergency intubation. In this clinical trial, we hypothesized that randomization to ketamine instead of etomidate would be associated with Day 7 survival after emergency endotracheal intubation.
Methods
A prospective, randomized, open-label, parallel assignment, single-center clinical trial performed by an anesthesiology-based Airway Team under emergent circumstances at one high-volume medical center in the United States. 801 critically ill patients requiring emergency intubation were randomly assigned 1:1 by computer-generated, pre-randomized sealed envelopes to receive etomidate (0.2–0.3 mg/kg, n = 400) or ketamine (1–2 mg/kg, n = 401) for sedation prior to intubation. The pre-specified primary endpoint of the trial was Day 7 survival. Secondary endpoints included Day 28 survival.
Results
Of the 801 enrolled patients, 396 were analyzed in the etomidate arm, and 395 in the ketamine arm. Day 7 survival was significantly lower in the etomidate arm than in the ketamine arm (77.3% versus 85.1%, difference − 7.8, 95% confidence interval − 13, − 2.4, p = 0.005). Day 28 survival rates for the two groups were not significantly different (etomidate 64.1%, ketamine 66.8%, difference − 2.7, 95% confidence interval − 9.3, 3.9, p = 0.294).
Conclusion
While the primary outcome of Day 7 survival was greater in patients randomized to ketamine, there was no significant difference in survival by Day 28.
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Availability of data and materials
Our IRB approval does not include provisions for sharing individual patient-level data.
Code availability
Not applicable.
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Acknowledgements
Our patients and their families. Parkland Hospital. UT-Southwestern Dept. of Anesthesiology & Pain Management Residency Program. Members of the UT-Southwestern/Parkland Community Advisory Panel, Bryan Elwood, Director. Collaborating members of our Airway Team (Faculty Anesthesiologists, Resident Anesthesiologists, Certified Registered Nurse Anesthetists) and ICU teams. Members of our DSMB: Amanda Fox, David McDonagh, Jennifer McGuire, Matthew Leveno. Monique Johnson, for extensive and important logistical and administrative support during post-enrollment notification activities. We used a REDCap database for this project [35], hosted by UT-Southwestern Medical Center. REDCap has requested that we acknowledge that REDCap is supported by NIH/NCATS CTSA Grant Number UL1 TR002535. Members of EvK Clinical Trial Collaborators: Anand M. Abraham: Department of Anesthesiology and Pain Management, UT-Southwestern Medical, Center, Dallas, TX, USA, Robert S. Ackerman: Department of Anesthesiology and Pain Management, UT-Southwestern Medical, Center, Dallas, TX, USA, Oluwafunmilayo B. Adebayo-Adonis: Department of Anesthesiology, Washington U. School of Medicine, St. Louis, MO, USA, Venkatesh Aiyagari: Dept. of Neurological Surgery and Neurology, UT-Southwestern Medical, Center, Dallas, TX, USA, Aditee P. Ambardekar: Department of Anesthesiology and Pain Management, UT-Southwestern Medical, Center, Dallas, TX, USA, Kelechi B. Anyaehie: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, David M. Bashover: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Matthew Burke Bourneuf: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA , James R. Brann II: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Grace Wilkowski Bryant: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Matthew P. Bunker: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Leigh Anne Catoe: Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA, Catherine Chen: Division of Pulmonary and Critical Care Medicine Department of Internal Medicine UT-Southwestern Medical Center Dallas, TX, USA, Jeffrey S. Chen: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Joy Lo Chen: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Gloria S. Cheng: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Ivan Nicholas Chew: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Jeanette L. Chin: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Samuel M. Cohen: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Mary Abigail Cowlishaw: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Janice Davis II: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Jennifer Lynn Davis: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, TomMario Alando Davis: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, David G. DePinto: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Paul E. Dilfer: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Renee D. Doherty: Department of Anesthesia and Pain Management, St. Louis Children's Hospital, Washington U. School of Medicine, St. Louis, MO, USA, Philip James DuChamp: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Katherine L. Duncan: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA Colin C. Ehlenbach: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Ahmad Elsharydah: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Sonia D. Estes: Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA, Akil Farishta: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, William Eric Foster: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, David G. Francis: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Shannon Garitty: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Nicholas W. Gill: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Louise A. Gliga: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Joseph Arthur Graham: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Nancy B. Greilich: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Jessica E. Grundt: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Allan J. Hamilton: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Hooman Heravi: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Douglas C. Huynh: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Ray K. Hwong: Department of Anesthesiology McGovern Medical School at UT-Health Houston, TX, USA, Rachel E. Jacobs: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Syed Jaffery: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Aveline P. Jerome: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Suja John: Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA, Enas Kandil: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Asif Khan: Dept. of Anesthesiology, Critical Care, & Pain Medicine, Boston Children's Hospital, Boston, MA, USA, Sarah M. Khorsand: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Jennifer Meeyun Kim: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Elena J. Koepke: Department of Anesthesiology McGovern Medical School UT Health Science Center at Houston, Houston, TX, USA, Grayson Jeffrey Koval: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Brian Kurtz: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Xuan T. Langridge: Department of Anesthesiology UTHealth McGovern Medical School Houston, TX, USA, Gene W. Lee: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Simon J. Craddock Lee: Dept. of Population & Data Sciences UT Southwestern Medical Center Dallas, TX, USA, Matthew J. Leveno: Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, UT-Southwestern Medical Center, Dallas, TX, USA, Dawn Lewellen: Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA, Frederick C. Li: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Nathaniel Loo: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Xi Luo: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Rachelle A. Makinde: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Anna E. Martin: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Evan Z. Mayes: Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA, Diane E. McCune: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, John McGrimley: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Jennifer J. McGuire: Parkland Health and Hospital System Pharmacy Administration Dallas, TX, USA, Kyle Meinhardt: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Akeel M. Merchant: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Zahid Merchant: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, David W. Mercier: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Brandon C. Mitchell: Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA, Andrea J. Murray: Dept. of Anesthesiology & Pain Management, Stanford University, Stanford, California, USA, Shamsideen O. Musa: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Geoffrey Edward Nelson: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Seth Nelson: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Le H. Nguyen: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Linsey Nohrn: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Osamudiamen O. Obanor: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Chinwe C. Ononogbu: Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA, Mihir Parikh: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Hetal J. Patel: Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, UT-Southwestern Medical Center, Dallas, TX, USA, John H. Pennant: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Paul E. Pepe: Department of Management, Policy and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA, Office of the Medical Director for Emergency Medical Services/Public Safety, Dallas, TX, USA, David Quang-Nam Pham: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Jenny Ringqvist: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, John A. Rosener: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Timothy J. Ryan: Department of Political Science University of North Carolina at Chapel Hill, Chapel Hill, NC, USA, Stephen Andrew Sarmiento: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Stephen W. Sawyer: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Nicholas A. Schilling: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Levi J. Schlegel: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Brady P. Selig: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Ben R. Sessions: Department of Anesthesiology and Pain anagement, UT-Southwestern Medical Center, Dallas, TX, USA, Mohammad-Ali Shaikh: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Eric Y. Siu: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Joseph T. Sofia: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Tristyn V. St. Thomas-Achoja: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Jonathan D. Stubblefield: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Ivy A. Taylor: Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA, Stephen M. Topper: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Coby Tran: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Michael Panganiban Tulio: Dept. of Anesthesiology & Pain Management Texas Children's Hospital/Baylor College, Houston, TX, USA, Emily R. Turner: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Steven Vela: Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA, Hayley Vickers: Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA, Daren Walters: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Juliana Watson: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Noel F. White: Department of Anesthesiology, Parkland Health and Hospital System, Dallas, TX, USA, Charles W. Whitten: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Brian H. Williams: Department of Surgery The University of Chicago Medicine & Biological Sciences, Chicago, IL, USA, Willis T. Williams: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Casey Wollenman: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Isabel Q. Wu: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Alla Yarmosh: Department of Anesthesiology and Pain Management, UT-Southwestern Medical Center, Dallas, TX, USA, Leila W. Zuo: Department of Anesthesiology & Perioperative Management Oregon Health & Science University Portland, OR, USA.
Funding
Internally Funded (UT-Southwestern Dept. of Anesthesiology & Pain Management, Dallas, TX USA).
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Authors and Affiliations
Consortia
Contributions
OA-Enrollment, manuscript drafting. BJB-Enrollment, manuscript drafting. CGE-Enrollment, manuscript drafting. BF-Study design, CRNA coordination, enrollment, manuscript drafting. PEF-Study design, data management and informatics, enrollment, manuscript drafting. IG-Study design, enrollment, manuscript drafting. LWL-Study design, enrollment, resident coordination, manuscript drafting. GM-Study PI, study design, enrollment, manuscript drafting. AM-Study Statistician, study design, statistical calculations, manuscript drafting. TSM-Study design, enrollment, manuscript drafting. DN-Study design, enrollment, manuscript drafting. BOO-Study design, enrollment, manuscript drafting. CAR-Study design, enrollment, manuscript drafting. MNS-Enrollment, manuscript drafting. JWS-Enrollment, manuscript drafting. MCS-Study design, CRNA coordination, enrollment, manuscript drafting. DT-Enrollment, manuscript drafting.
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Conflicts of interest
CAR: Receives compensation for serving on the Medical Advisory Board for Vyaire. The other coauthors declare no conflicts-of-interest, and no competing interests.
Ethical approval
This trial (NCT02643381, UTSW IRB STU022015-023) received contingent Institutional Review Board (IRB) approval on 28 October 2015, and full approval on 30 November 2015. Continuing Reviews were completed and approved on 19 August 2016, 3 August 2017, 26 July 2018, 7 August 2019, and 7 August 2020.
Consent to participate
This clinical trial received IRB approval to be conducted as an Exception-from-Informed-Consent trial under emergency clinical circumstances.
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Enrolled patients and/or their survivors were notified of enrollment and given an opportunity to opt-out of data collection and inclusion.
PI data statement
The study PI (GM) is responsible for the veracity of all study data and all aspects of this manuscript.
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The EvK Clinical Trial Collaborators are mentioned in “Acknowledgement” section.
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Matchett, G., Gasanova, I., Riccio, C.A. et al. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med 48, 78–91 (2022). https://doi.org/10.1007/s00134-021-06577-x
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DOI: https://doi.org/10.1007/s00134-021-06577-x