Comparative Analysis of Ketamine and Etomidate: Perioperative Outcomes in Critically Ill Patients

Randomized data now clarify the clinical trade‑offs between ketamine and etomidate for induction before tracheal intubation, suggesting there is no clear mortality advantage at 28 days.

The trial enrolled critically ill adults undergoing tracheal intubation across emergency and ICU settings and used day‑28 in‑hospital mortality as the primary outcome, focusing the comparison on short‑term survival. In-hospital all-cause death by day 28 was 28.1% with ketamine induction versus 29.1% with etomidate. The between-group difference did not reach statistical significance for the day-28 endpoint.

The investigators attributed higher immediate peri‑induction hemodynamic instability to ketamine, citing cardiovascular collapse during intubation in 22.1% after ketamine versus 17.0% after etomidate. Ketamine use demands heightened vigilance for abrupt hemodynamic deterioration in the induction window.

Synthesis of the trial’s other prespecified safety outcomes showed no large imbalances between arms. Etomidate’s known potential for transient adrenal suppression and ketamine’s psychotomimetic emergence phenomena were noted as contextual risks but did not translate into clear, dominant harms in the prespecified comparisons. Subgroup analyses (for example, septic shock, major trauma, and baseline hemodynamic instability) did not reveal consistent, clinically meaningful interactions favoring one agent.

Key Takeaways:

• A randomized trial shows no meaningful difference in 28‑day in‑hospital mortality between ketamine and etomidate, indicating mortality parity and the need to prioritize other outcomes when choosing an induction agent.
• Critically ill adults undergoing tracheal intubation are the population most directly impacted; patients with immediate hemodynamic fragility are particularly relevant to agent selection and monitoring priorities.