Background: Sepsis is a common cause of respiratory failure, and the optimal induction agent for septic patients has been controversial. Our study aims to describe variation in medication choices for intubation in the ED among sepsis and non-sepsis patients, with a secondary outcome of measuring the association between medications and adverse events.
Methods: This is a secondary analysis of a multicenter observational intubation registry, The National Emergency Airway Registry (NEAR). Outcomes include intubation success and adverse events (desaturation, hypotension, vasopressor use, and death in the ED). Chi squared test was used for comparison of categorical variables, and Wilcoxon rank sum test was used for comparison of continuous variables. All proportions were adjusted for clustering.
Results: A total of 531 patients with sepsis were compared to all 12,191 non-sepsis cases. Etomidate was used as an induction agent more frequently among non-sepsis patients (84.6% vs. 70.8%, OR=4.9, 95%CI 4.1-6.0), while ketamine was used more frequently among sepsis patients (27.3% vs. 11.7%, OR=3.4, 95%CI 2.8-4.1). Sepsis patients experienced more adverse events (23.1% vs. 11.7%, OR=2.3, 95%CI 1.8-2.8), including post-intubation hypotension (46.7% vs. 17.4%, OR=5.0, 95%CI 4.2-6.0), post-intubation treatment for hypotension (86.7% vs. 78.6%, OR=1.8, 95%CI 1.2-2.6), and post-procedure vasopressor administration (24.9% vs. 7.5%, OR=4.1, 95%CI 3.3-5.0). Sepsis patients induced with ketamine compared to etomidate received more pre-treatment with epinephrine (4.3% vs. 0.6%, OR=7.5, 95%CI 1.7- infinity) and norepinephrine (12.1% vs. 4.1%, OR=3.0, 95%CI 1.4-6.0), but post-procedure hypotension (54.7% vs. 45.1%, OR=1.4, 95%CI 0.6-3.3) was not different. Non-sepsis patients intubated with ketamine experienced more adverse outcomes (19.4% vs. 11.8%, OR=1.8, 95%CI 1.5-2.1) and were more likely to have a difficult airway (44.6% vs. 30.6%, OR=1.8, 95%CI 1.6-2.1) compared to etomidate.
Conclusions: Etomidate was used less frequently in sepsis patients, and ketamine was used more frequently. This may indicate ketamine is associated with more adverse events, or ketamine was used with patients who were more ill. Future work should examine the relationship between ketamine and peri-intubation adverse events among patients intubated for sepsis.