Choice of Anesthetic Induction Drugs for Tracheal Intubation in Critically Ill Patients and Impact on Outcomes: A Systematic Review
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BACKGROUND: Airway management in critically ill patients can significantly impact patient outcomes, and the choice of induction drugs used for endotracheal intubation (TI) is key for a successful and safe airway management. However, critically ill patients often have physiologic derangements leading to complications such as hypoxemia, hypotension, arrythmias, and cardiac arrest. HYPOTHESIS: This review aims to analyze the usage and outcomes of induction drugs used for airway management in critically ill adult patients to determine if there are select induction drugs that have better success rates and patient outcomes. METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE for randomized controlled trials published since January 1, 2003, on critically ill adult patients who underwent TI in an emergency, ICU, or trauma setting. Our search yielded 1526 results, of which 18 were chosen. FINDINGS: These 18 studies include 15 randomized control trials, 2 ongoing phase 4 clinical trials, and 1 single blinded randomized study, for a total of 3142 patients. Etomidate and ketamine were the two most common drugs used, with 13 studies involving the use of etomidate, for a total of 1470 patients, and 7 studies involving the use of ketamine, for a total of 1082 patients. Etomidate and ketamine were compared the most frequently (n = 7), followed by etomidate and midazolam (n = 4). Most studies were performed in either the ICU (n = 6) or the ED/ER (n = 5). Hospital mortality (n = 10) and peri-intubation hypotension (n = 11) were also the most common outcomes studied. CONCLUSIONS: In general, there was no major trend that could be identified regarding patient outcomes when two induction drugs were compared with each other. This was due to the variability in the use of induction drugs for TI in critically ill patients and their patient outcomes. Comparing findings of different studies was limited by the heterogeneity of the studies. Further research is needed to identify the impact of the choice of induction drugs for TI in critically ill patients.