Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial
Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial
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DOI：
10.1016/s0140-6736(09)60949-1
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发表时间：
2009-07-25
期刊：
影响因子：
168.9
通讯作者：
Adnet, Frederic
中科院分区：
文献类型：
--
作者：
Jabre, Patricia;Combes, Xavier;Adnet, Frederic
背景危重患者通常需要紧急插管。在这种情况下，依托咪酯作为镇静剂的使用受到了挑战，因为它可能导致可逆性肾上腺功能不全，可能与医院内发病率增加有关。我们比较了危重病患者单剂量依托咪酯或氯胺酮用于紧急气管插管后的早期和28天的发病率。方法在这项随机对照单盲试验中，来自法国12个急诊医疗服务或急诊科和65个重症监护病房的655名需要镇静的紧急插管患者进行前瞻性研究。患者由计算机随机数字生成器列表随机分配，接受0.3 mg/kg依托咪酯(n=328)或2 mg/kg氯胺酮(n=327)插管。只有招募患者的急诊医生知道分组分配。主要终点是重症监护病房前3天连续器官衰竭评估的最高分。我们从分析中排除了在到达医院前死亡的患者或在3天前从重症监护病房出院的患者(修改治疗意向)。这项试验在ClinicalTrials.gov注册，编号为NCT00440102。结果分析了依托咪酯组234名患者和氯胺酮组235名患者。两组平均最大SOFA评分差异无统计学意义(依托咪酯10.3[SD3.7]vs氯胺酮9.6[3.9]；平均差异0.7[95%可信区间0.0~1.4]，p=0.056)。两组插管条件无显著差异(两组插管难度中位数评分均为1[IQR0~3]；p=0.70)。依托咪酯组肾上腺功能不全患者的比例显著高于氯胺酮组(OR 6.7，3.5-12.7)。我们没有记录任何一种研究药物的严重不良事件。解释说，我们的结果表明，氯胺酮是危重患者气管插管时依托咪酯的安全和有价值的替代品，应该考虑用于脓毒症患者。
Background Critically ill patients often require emergency intubation. The use of etomidate as the sedative agent in this context has been challenged because it might cause a reversible adrenal insufficiency, potentially associated with increased in-hospital morbidity. We compared early and 28-day morbidity after a single dose of etomidate or ketamine used for emergency endotracheal intubation of critically ill patients.Methods In this randomised, controlled, single-blind trial, 655 patients who needed sedation for emergency intubation were prospectively enrolled from 12 emergency medical services or emergency departments and 65 intensive care units in France. Patients were randomly assigned by a computerised random-number generator list to receive 0.3 mg/kg of etomidate (n=328) or 2 mg/kg of ketamine (n=327) for intubation. Only the emergency physician enrolling patients was aware of group assignment. The primary endpoint was the maximum score of the sequential organ failure assessment during the first 3 days in the intensive care unit. We excluded from the analysis patients who died before reaching the hospital or those discharged from the intensive care unit before 3 days (modified intention to treat). This trial is registered with ClinicalTrials.gov, number NCT00440102.Findings 234 patients were analysed in the etomidate group and 235 in the ketamine group. The mean maximum SOFA score between the two groups did not differ significantly (10.3 [SD 3.7] for etomidate vs 9.6 [3.9] for ketamine; mean difference 0.7 [95% CI 0.0-1.4], p=0.056). Intubation conditions did not differ significantly between the two groups (median intubation difficulty score 1 [IQR 0-3] in both groups; p=0.70). The percentage of patients with adrenal insufficiency was significantly higher in the etomidate group than in the ketamine group (OR 6.7, 3.5-12.7). We recorded no serious adverse events with either study drug.Interpretation Our results show that ketamine is a safe and valuable alternative to etomidate for endotracheal intubation in critically ill patients, and should be considered in those with sepsis.