Ketamine or etomidate? Whats your go to induction agent for decompensating, hypotensive patients?
Ketamine or etomidate? Whats your go to induction agent for decompensating, hypotensive patients? Etomidate and ketamine are commonly used agents given their pharmacokinetic profile and therapeutic mechanisms. Etomidate, as a GABA agonist, is considered to cardiovascular neutral with a terminal half life of up to 5 hours. Ketamine, a NMDA antagonist, dissociates the brain from external stimuli and is known to be more adrenergic via catecholamine reuptake inhibition.
The debate? Etomidate is known to cause adrenal insufficiency by inhibiting 11-β hydroxylase with evidence leaning towards neglible effect after 1 dose. The minor mechanism of ketamine is its negative inotropic effects and may overcome catecholamine inhibition if theres no circulating catecholamines, sounds like our crashing whos been down for two days. Comparative, retrospective, and meta-analysis all provide differing conclusions.
Its up to you to read the literature and make that choice yourself for the patient in front of you. My thoughts are go with what you think is best and cut your dose per patient hemodynamics. Obtunded, comatose patients don’t need full dose induction as theres such a thing as drug-induced toxicities and inducing even more hemodynamic compromise. Keep vasopressors handy; either PDP or premixed bags for all excursions in the ED. For more PHARMFAX in the drug bank, check out another video on my page, make sure to give me a follow, and I hope you learned something new.
Recommended Read/Watch
Induction Agents Overview: https://shorturl.at/pvACJ
Induction Agent Pharmacokinetics: https://shorturl.at/iDM15
The ALL PHARMWYZE SOURCE (including references)
www.pharmwyze.com
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Not medical advice. Educational purposes only. No relationships to report.
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