Ketamine and midazolam differently impact post-intubation hemodynamic profile when used as induction agents during emergency airway management in hemodynamically stable patients with ST elevation myocardial infarction
We investigated the incidence of post-intubation hypotension (PIH) in hemodynamically stable patients with STEMI requiring rapid sequences intubation (RSI) and medicated with ketamine or midazolam as induction agent. STEMI patients admitted between 1st January 2009 and 1st January 2017 who did not receive any type of inotropic support before the endotracheal intubation (ETI) was reviewed. PIH was defined as a reduction greater than 20% or a drop of systolic blood pressure (SBP) below 90 mmHg within 10 min from the administration of the induction agent [ketamine (1 mg/kg) or midazolam (0.3 mg/kg)]. Over the study period, 136 patients (66 male and 70 females, mean age 72.25 ± 7.33 years) met the inclusion criteria. Patients treated with midazolam and ketamine were 63 and 73, respectively. PIH was observed in 38 (27.9%) patients after 10 min from ETI. Midazolam patients had a significant lower SBP at both 5 and 10 min after induction (97.75 ± 8.06 vs 100.81 ± 8.08, p = 0.029 and 92.83 ± 7.53 vs 101.58 ± 7.29, p < 0.0001, respectively) (ANOVA p < 0.0001). Age (OR 1.91, 95% CI 1.87–1.97, p = 0.001), history of arterial hypertension (OR 2.27, 95% CI 2.21–2.35, p = 0.0001), multivessel coronary artery disease (OR 2.66, 95% CI 2.58–2.71, p = 0.001), SI ≥0.9 (OR 2.41, 95% CI 2.36–2.48, p < 0.0001) and anterior STEMI (OR 2.51, 95% CI 2.48–2.57, p = 0.0001) resulted independent predictors of PIH in STEMI patients treated with midazolam, as induction agent, before ETI. Midazolam was more likely than ketamine to cause significant PIH when used as an induction agent for RSI in hemodynamically stable patients with STEMI.
KeywordsPost-intubation hypotension STEMI Induction agents
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Conflict of interest
None of the authors have conflict of interest to declare.
- 3.Pesaro AE, Katz M, Katz JN, Barbas CS, Makdisse MR, Correa AG, Franken M, Pereira C, Serrano CV Jr, Lopes RD (2016) Mechanical ventilation and clinical outcomes in patients with acute myocardial infarction: a retrospective observational study. PLoS ONE 11:e0151302CrossRefPubMedPubMedCentralGoogle Scholar
- 7.Smischney NJ, Ricter BD, Hoeft CC, Johnson LM, Ansar S, Kashyap R (2014) Association of post-intubation hemodynamic instability in an adult ICU with in-hospital mortality and ICU length of stay. Am J Respir Crit Care Med 189:A4558Google Scholar
- 9.Stolfo D, Cinquetti M, Merlo M, Santangelo S, Barbati G, Alonge M, Vitrella G, Rakar S, Salvi A, Perkan A, Sinagra G (2016) ST-elevation myocardial infarction with reduced left ventricular ejection fraction: insights into persisting left ventricular dysfunction. A pPCI-registry analysis. Int J Cardiol 15(215):340–345CrossRefGoogle Scholar
- 12.Zuin M, Rigatelli G, Picariello C, dell’Avvocata F, Marcantoni L, Pastore G, Carraro M, Nanjundappa A, Faggian G, Roncon L (2017) Correlation and prognostic role of neutrophil to lymphocyte ratio and SYNTAX score in patients with acute myocardial infarction treated with percutaneous coronary intervention: a six-year experience. Cardiovasc Revasc Med. doi: 10.1016/j.carrev.2017.05.007 Google Scholar
- 18.Jaber S, Amraoui J, Lefrant JY, Arich C, Cohendy R, Landreau L, Calvet Y, Capdevila X, Mahamat A, Eledjam JJ (2006) Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med 34:2355–2361CrossRefPubMedGoogle Scholar
- 24.Behar S, Rabinowitz B, Zion M, Reicher-Reiss H, Kaplinsky E, Abinader E, Agmon J, Friedman Y, Kishon Y, Palant A, Peled B, Reisin L, Schlesinger Z, Zahavi I, Goldbourt U (1993) Immediate and long-term prognostic significance of a first anterior versus first inferior wall Q-wave acute myocardial infarction. Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) study group. Am J Cardiol 72:1366–1370CrossRefPubMedGoogle Scholar