Procedures · Induction agent for intubation
Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults
| Design | Phase 4 multicentre randomised controlled trial |
|---|---|
| Treatment | Ketamine for induction |
| Control | Etomidate for induction |
| Population | 2365 critically ill adults undergoing tracheal intubation: 1176 ketamine and 1189 etomidate |
| Follow-up | 28 days |
| Primary endpoint | In-hospital death by day 28 |
| Result | In-hospital death by day 28 occurred in 330 of 1173 (28.1%) with ketamine and 345 of 1186 (29.1%) with etomidate — adjusted risk difference -0.8 percentage points (95% CI -4.5 to 2.9, p=0.65). The prespecified secondary outcome went the other way: cardiovascular collapse during intubation occurred in 260 of 1176 (22.1%) with ketamine versus 202 of 1189 (17.0%) with etomidate — risk difference 5.1 percentage points (95% CI 1.9 to 8.3). Prespecified safety outcomes were similar. |
| Secondary endpoints | Cardiovascular collapse during intubation, prespecified safety outcomes |
Among critically ill adults undergoing tracheal intubation, the use of ketamine to induce anesthesia did not result in a significantly lower incidence of in-hospital death by day 28 than etomidate.
The trial authors, in the published abstract
Settles a long-running dispute about etomidate's adrenal suppression by testing the outcome that matters rather than the cortisol level. Mortality is identical. The trial's one prespecified secondary outcome, however, favoured etomidate: cardiovascular collapse was 5 percentage points more common with ketamine. Haemodynamics argue, if anything, for etomidate rather than against it.
Casey JD, Seitz KP, Driver BE, et al. Ketamine or Etomidate for Tracheal Intubation of Critically Ill Adults. N Engl J Med 2026 Apr 23;394(16):1608-1620.