Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation.
Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation.
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DOI：
10.1016/j.ajem.2022.08.054
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发表时间：
2022-11
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急诊科（艾德）接受紧急气管插管的患者通常有多种生理紊乱，使他们面临插管后低血压的风险。先前的研究表明，插管后低血压与发病率和死亡率的增加独立相关。诱导剂的选择可能与插管后低血压有关。依托咪酯和氯胺酮是艾德中最常用的两种药物，然而，关于这两种药物在血流动力学不稳定的情况下是否具有上级优势存在争议。本研究的目的是确定接受氯胺酮或依托咪酯诱导的插管后低血压发生率是否存在差异。此外，我们对预先存在心血管虚脱风险（通过插管前休克指数（SI）> 0.9确定）的患者进行了亚组分析，以确定插管后低血压的发生率是否存在差异，这是这些高危患者在气管插管期间使用镇静剂的功能。我们假设接受氯胺酮和依托咪酯的患者插管后低血压的发生率没有差异。在一个大型学术卫生系统中，对469例接受依托咪酯或氯胺酮诱导紧急插管的患者数据库进行了一项回顾性队列研究。通过自动查询2016年1月1日至2019年6月30日的电子健康记录识别患者。排除标准为<18岁、在艾德外进行气管插管、插管前后生命体征不完整或插管前心脏骤停的患者。通过插管前SI > 0.9确定插管后血流动力学崩溃高风险患者。主要结局是插管后低血压（收缩压< 90 mmHg或平均动脉压< 65 mmHg）的发生率。次要结局包括插管后血管加压药的使用和死亡率。这些分析是在全队列中进行的，并对SI > 0.9的患者进行了探索性分析。我们还报告了来自整个队列的多变量logistic回归模型的调整优势比（aOR），控制合理的混杂变量，以确定与插管后低血压相关的独立因素。共纳入358例患者（依托咪酯：272例;氯胺酮：86例）。氯胺酮组的平均插管前SI高于依托咪酯组（0.97 vs. 0.83，差异：-0.14（95%，CI-0.2至-0.1）。SI分层前，氯胺酮组插管后低血压的发生率较高（差异：− 10%，95%CI −20.9%至-0.1%）。在SI > 0.9的患者中，急诊医生更有可能使用氯胺酮。在我们的多变量logistic回归分析中，诱导剂的选择与插管后低血压无关（aOR 1.45，95%CI 0.79 - 2.65）。我们发现插管前休克指数是插管后低血压的最强预测因素。在我们接受紧急气管插管的患者队列中，休克指数升高的患者更常使用氯胺酮。我们没有发现氯胺酮和依托咪酯之间插管后低血压的发生率与诱导剂之间的相关性。无论选择氯胺酮还是依托咪酯，休克指数升高的患者发生心血管性虚脱的风险更高。
Emergency department (ED) patients undergoing emergent tracheal intubation often have multiple physiologic derangements putting them at risk for post-intubation hypotension. Prior work has shown that post-intubation hypotension is independently associated with increased morbidity and mortality. The choice of induction agent may be associated with post-intubation hypotension. Etomidate and ketamine are two of the most commonly used agents in the ED, however, there is controversy regarding whether either agent is superior in the setting of hemodynamic instability. The goal of this study is to determine whether there is a difference in the rate of post-intubation hypotension who received either ketamine or etomidate for induction. Additionally, we provide a subgroup analysis of patients at pre-existing risk of cardiovascular collapse (identified by pre-intubation shock index (SI) > 0.9)to determine if differences in rates of post-intubation hypotension exist as a function of sedative choice administered during tracheal intubation in these high-risk patients. We hypothesize that there is no difference in the incidence of post-intubation hypotension in patients who receive ketamine versus etomidate. A retrospective cohort study was conducted on a database of 469 patients having undergone emergent intubation with either etomidate or ketamine induction at a large academic health system. Patients were identified by automatic query of the electronic health records from 1/1/2016 - 6/30/2019. Exclusion criteria were patients <18-years-old, tracheal intubation performed outside of the ED, incomplete peri-intubation vital signs, or cardiac arrest prior to intubation. Patients at high risk for hemodynamic collapse in the post-intubation period were identified by a pre-intubation SI > 0.9. The primary outcome was the incidence of post-intubation hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg). Secondary outcomes included post-intubation vasopressor use and mortality. These analyses were performed on the full cohort and an exploratory analysis in patients with SI > 0.9. We also report adjusted odds ratios (aOR) from a multivariable logistic regression model of the entire cohort controlling for plausible confounding variables to determine independent factors associated with post-intubation hypotension. A total of 358 patients were included (etomidate: 272; ketamine: 86). The mean pre-intubation SI was higher in the group that received ketamine than etomidate, (0.97 vs. 0.83, difference: −0.14 (95%, CI −0.2 to −0.1). The incidence of post-intubation hypotension was greater in the ketamine group prior to SI stratification (difference: −10%, 95% CI −20.9% to -0.1%). Emergency physicians were more likely to use ketamine in patients with SI > 0.9. In our multivariate logistic regression analysis, choice of induction agent was not associated with post-intubation hypotension (aOR 1.45, 95% CI 0.79 to 2.65). We found that pre-intubation shock index was the strongest predictor of post-intubation hypotension. In our cohort of patients undergoing emergent tracheal intubation, ketamine was used more often for patients with an elevated shock index. We did not identify an association between the incidence of post-intubation hypotension and induction agent between ketamine and etomidate. Patients with an elevated shock index were at higher risk of cardiovascular collapse regardless of the choice of ketamine or etomidate.
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