(O-J5) Sedative Dose for Rapid Sequence Intubation and Post-intubation Hypotension: Is There an Association?

Objectives: We sought to determine if an association existed between the weight-based dose of etomidate or ketamine and subsequent post-intubation hypotension.

Background: For patients with hemodynamic instability or shock undergoing rapid sequence intubation, experts recommend reducing the sedative medication dose to minimize the risk of further hemodynamic deterioration. There are little data to support this practice for etomidate and ketamine, the most used sedatives.

Methods: We analyzed data from the National Emergency Airway Registry from January 2016 to December 2018. Patients aged 14 years or older were included if the first intubation attempt was facilitated with etomidate or ketamine. We used multivariable modeling to determine whether drug dose in milligrams per kilogram of patient weight was independently associated with post-intubation hypotension (systolic blood pressure < 100 mm Hg).

Results: We analyzed 12,175 intubation encounters facilitated by etomidate and 1,849 facilitated by ketamine. The median drug doses were 0.28 mg/kg (interquartile range [IQR] 0.22 mg/kg to 0.32 mg/kg) for etomidate and 1.33 mg/kg (IQR 1 mg/kg to 1.8 mg/kg) for ketamine. Post-intubation hypotension occurred in 1,976 patients (16.2%) who received etomidate and in 537 patients (29.0%) who received ketamine. In multivariable models neither etomidate dose (adjusted odds ratio [aOR] 0.95, 95% CI 0.90–1.01) nor ketamine dose (aOR 0.97, 95% CI 0.81–1.17) were associated with post-intubation hypotension. Results were similar in sensitivity analyses excluding patients with pre-intubation hypotension and including only patients intubated for shock.

Conclusions: In this large registry of patients intubated after receiving either etomidate or ketamine, we observed no association between the weight-based sedative dose and post-intubation hypotension.

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Funding (Optional): Not applicable