Induction Agents Have Similar Haemodynamic Effects With Trauma Intubation in Emergency Department

October 8, 2020

By Nancy Melville

YORK, Me -- October 8, 2020 -- No significant differences are seen in the haemodynamic effects of the 3 common induction agents etomidate, ketamine, and propofol during rapid sequence intubation of trauma patients, despite some known differences between the agents, according to a study presented at the 2020 Virtual Meeting of the American College of Surgeons (ACS).

“Contrary to our hypothesis, there was no difference in the haemodynamic effects for etomidate versus ketamine versus propofol during rapid sequence intubation in trauma patients,” said Emily B. Leede, University of Texas, Austin, Texas

Although all 3 agents can be beneficial in the induction of rapid sequence intubation, they are associated with different haemodynamic profiles that, in certain cases, could be a concern in trauma resuscitations. Whereas etomidate is believed to be haemodynamically stable, propofol has been associated with hypotension, and ketamine is known to have sympathomimetic effects, including possible increases in heart rate and blood pressure. However, research is lacking on how the agents compare in the setting of rapid sequence intubation.

For the multicentre study, Leede and colleagues evaluated data on 2,092 adult trauma patients who were admitted to 8 ACS-verified level 1 trauma centre emergency departments between 2014 and 2019 and received rapid sequence intubation in the emergency department. Among the patients, 85% received etomidate, 8% received ketamine, and 7% received propofol.

Patients in the ketamine group had lower systolic blood pressure before intubation (etomidate, 135 mg Hg; ketamine, 125 mm HG ; propofol, 135 mm Hg; P = .04); however, no differences were seen between the groups in pulse rate (etomidate, 104 bpm; ketamine, 107 bpm; propofol, 105 bpm; P = .45).

The groups showed no significant differences in the average change in systolic blood pressure during rapid sequence intubation (etomidate, -1.9 mm Hg; ketamine, -5.2 mm Hg; propofol, 1.8 mm Hg; P = .40) or changes in pulse rate (-1.7 bpm; -3.5 bpm; and 0.96 bpm, respectively; P = .24).

For secondary outcomes, propofol was associated with significantly fewer deaths (10 vs 18 with etomidate and 23, ketamine; P = .01), and more patients were discharged to home with propofol (56 vs 45 for etomidate and 44 ketamine; P = .05). No differences were seen between the groups in days spent in the hospital, days in the intensive care unit, and discharge to acute care, rehabilitation, or nursing home.

Regression analysis showed that propofol remained associated with decreased mortality (odds ratio, 0.4; P = .003).

Other factors that remained significantly associated with mortality included age, blunt trauma, and a low Glasgow Coma Scale and Injury Severity score (P

“We found no differences in the haemodynamic effects of etomidate compared with ketamine and propofol,” Leede said. “The hospital outcomes between ketamine and etomidate were the same, while propofol was associated with decreased mortality versus etomidate.”
[Presentation title: A Multicenter Investigation of the Hemodynamic Effects of Induction Agents for Trauma Rapid Sequence Intubation]