Ketamine versus Etomidate as an induction agent for tracheal intubation: An updated meta-analysis of randomized clinical trials
- Journal
- Anaesthesia, critical care & pain medicine (Q1)
- Published
- 22 September 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Mohammed A Elbahloul, Aliaa Gamal, Ahmed Amir Samir, Ehab Mohamed Elhebishy, Omar ElSayed Rageh
- PMID
- 42772417
- DOI
- 10.1016/j.accpm.2026.101910
Why clinicians should know about it
- Picked for Anesthesiology and Pain Medicine (paper of the day, 25 September 2026): Phase III RCT, practice-changing for induction agent choice
Abstract
BACKGROUND: Emergency tracheal intubation is a critical and life-saving intervention. However, the selection between ketamine and etomidate as induction agents for emergency tracheal intubation remains controversial. This updated systematic review and meta-analysis aims to compare ketamine and etomidate as induction agents for rapid sequence intubation in critically ill patients. METHODS: Five electronic databases were searched for randomized clinical trials (RCTs) evaluating ketamine and etomidate in critically ill patients. Observational studies were excluded. The primary outcome was mortality at the longest follow-up. The dichotomous outcomes were reported as risk ratios (RRs), and continuous outcomes as mean differences (MDs) with 95% confidence intervals (CI). RESULTS: Eight studies, enrolling 4,807 patients, were included. Ketamine and etomidate showed no significant difference in mortality (RR: 0.97, 95% CI: 0.89-1.06, p = 0.51). Additionally, survival was similar between ketamine and etomidate across both time points (24 h and 7 d). However, ketamine was associated with a significantly higher risk of post-induction cardiovascular collapse (RR: 1.34, 95% CI: 1.16-1.54, p < 0.01). CONCLUSION: Neither ketamine nor etomidate conferred a survival advantage in critically ill patients. However, ketamine was associated with a higher risk of post-induction cardiovascular collapse based on a pooled analysis of two open-label trials, whereas etomidate was associated with a higher risk of adrenal insufficiency. The certainty of the evidence for cardiovascular collapse is limited by the small number of studies, the open-label design, and heterogeneity in the outcome definitions. REGISTRATION: PROSPERO (CRD420261361259).
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.