Journal of Anesthesiology & Clinical Science

Journal of Anesthesiology & Clinical Science

ISSN 2049-9752
Original Research

Hemodynamic monitoring by USCOM during rapid sequence intubation (RSI) with Etomidate/Fentanyl or Ketamine/Midazolam

Sandra Geiger1, Hans Joachim Stemmler1*, Nina Strecker1, Johanna Tischer1, Alessandro Pastore1, Andreas Hausmann1 and Sophia Horster2

Correspondence: Stemmler HJ

1. Medical Dept. III Intensive Care Unit F 2 b/c, Ludwig-Maximilians University of Munich,Campus Großhadern, Munich, Germany.

Author Affiliations

2. Medical Dept. II, Intensive Care Unit F 2 b/c, Ludwig-Maximilians University of Munich,Campus Großhadern, Munich, Germany.


Background: Critically ill and septic patients often require emergency orotracheal intubation. Etomidate is associated with a reversible adrenal insufficiency which potentially increases the in-hospital mortality, particularly in patients with sepsis. Moreover; standard anesthetization might severely aggravate shock symptoms during rapid sequence induction (RSI). Ketamine with its known stabilizing effects on hemodynamics might be a reasonable alternative, particularly in septic patients.

Methods: This non-randomised, observational pilot study focuses on the influence of ketamine-based (K) vs an etomidate-based (E) anesthetization on hemodynamic parameters during RSI. Forty pts were assigned alternately to etomidate/fentanyl (n=20), or ketamine/midazolam (n=20) while monitoring with invasive blood pressure (IBP) and ultrasound cardiac output monitor (USCOM) measurements during RSI. The levels of vasopressors required prior to, during and after RSI were recorded.

Results: Fourty patients (median SAPS II score at ICU admission: 54 K, 50 E; median age: 59 yrs K, 56 yrs E) who needed sedation for emergency intubation were sedated either with etomidate/fentanyl or ketamine/midazolam. Noradrenalin demand and mean arterial pressure (MAP) prior to RSI were comparable (E: mean NA dose 0.2 mg/h, MAP 88 mmHg; K: mean NA dose 0.45 mg/h, MAP 75 mmHg) between the two groups. Moreover, mean MAP levels post RSI were 75 (E) and 76 (K) mmHg, respectively. The mean peak level of noradrenalin demand during RSI, though, was considerably higher within the etomidate group compared to the ketamine group (E 7.6 mg/h vs K 1.06 mg/h, p 0.01). Stroke volume index (SVI) and cardiac index (CI) increased during RSI (+3.8%/+3.0%) within the ketamine group, while SVI and CI decreased during RSI (-8.5%/-3.5%) within the etomidate group.

Conclusion: USCOM is an easily applicable and quick tool for the hemodynamic monitoring of critical ill patients. Moreover, this pilot study shows that RSI with ketamine/midazolam is a safe and valuable alternative to etomidate/ fentanyl in patients who primarily require vasopressors.

Keywords: Hemodynamic monitoring, USCOM, intubation, RSI, ketamine, etomidate

ISSN 2049-9752
Volume 1
Abstract Download