Retrospective Study on Mortality and Adrenal Insufficiency Following Emergency Intubation With Etomidate Versus Ketamine in Children

TL;DR

This study compares the risks of adrenal insufficiency and mortality in children after emergency intubation using etomidate or ketamine, finding no significant difference in mortality and lower adrenal suppression with etomidate.

Contribution

The study provides new evidence that etomidate does not increase adrenal insufficiency risk in children compared to ketamine during emergency intubation.

Findings

Etomidate was associated with significantly lower risk of adrenal suppression compared to ketamine (1.8% vs. 4.2%).

There was no difference in mortality between patients intubated with etomidate or ketamine.

Results remained consistent with and without propensity matching.

Abstract

Background: Etomidate is a sedative-hypnotic used for intubation in children. Its use in airway management has been controversial since etomidate may induce adrenal insufficiency. Ketamine is frequently used for intubation in children and has not been reported to be associated with adrenal insufficiency. We evaluated the risk of death and adrenal suppression after rapid sequence intubation (RSI) with either etomidate or ketamine.

Methods: This retrospective study was performed using the TriNetX database in the United States from 61 healthcare organizations (HCOs). The final cohort after propensity matching included 1,191 patients who were ≤17 years of age and were given etomidate or ketamine for RSI but not both. The time frame was from December 22, 2003, to October 22, 2022.

Results: After propensity matching, the etomidate and ketamine groups each contained 565 patients, and there was a significantly lower risk of adrenal suppression with etomidate (1.8%) compared to ketamine (4.2%) (RR=0.43, 95% CI=0.21-0.90, p=0.02). There were similar results regarding adrenal insufficiency when no propensity matching was performed. There were no differences in mortality when comparing intubation with etomidate or ketamine with and without propensity matching.

Conclusion: There was not an increased risk of adrenal insufficiency for etomidate administered as a single dose in children undergoing RSI in the emergency department (ED) when compared with ketamine. Additionally, there was no difference in mortality for those intubated with ketamine or etomidate.