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PACULit Literature Updates September 2025: Emergency Medicine & Critical Care

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  1. Use of a drug-related problem oriented medical record in the medication review of critically ill patients Randomized clinical trial
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  2. PACULit Daily Literature Update: Stress hyperglycemia ratio as a biomarker for early mortality risk stratification in cardiovascular disease a propensity matched analysis
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  3. PACULit Daily Literature Update: Initial serum electrolyte imbalances and mortality in patients with traumatic brain injury a retrospective study
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  4. PACULit Daily Literature Update: AsNeeded AlbuterolBudesonide in Mild Asthma
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  5. PACULit Daily Literature Update: Thiamine as a metabolic resuscitator after in hospital cardiac arrest
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  6. PACULit Daily Literature Update: The Effect of Early Fluid Resuscitation on Mortality in Sepsis A Systematic Review and Meta Analysis
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  7. PACULit Daily Literature Update: Inhaled isoflurane for sedation of mechanically ventilated children in intensive care (IsoCOMFORT): a multicentre, randomised, active-control, assessor-masked, non-inferiority phase 3 trial
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  8. PACULit Daily Literature Update: Prevalence risk factors and consequences of early clinical deterioration under noninvasive ventilation in emergency department patients a prospective multicentre observational study of the French IRU Network
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  9. PACULit Daily Literature Update: Evaluation of Stress Dose Hydrocortisone Tapers in Septic Shock
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  10. Opportunistic Screening for Atrial Fibrillation With Continuous ECG Monitoring in the Emergency Department
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  11. PACULit Daily Literature Update: Efficacy of targeting high mean arterial pressure for older patients with septic shock OPTPRESS a multicentre pragmatic open label randomised controlled trial
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  12. PACULit Daily Literature Update: Evaluation of Etomidate Use and Association with Mortality Compared with Ketamine among Critically Ill Patients
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  13. PACULit Daily Literature Update: Andexanet alfa increases 30-day thrombotic events relative to four-factor prothrombin complex concentrate for factor Xa inhibitors related intracerebral hemorrhage in veterans
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  14. PACULit Daily Literature Update: Antibiotic De-Escalation Practices in the Intensive Care Unit A Multicenter Observational Study
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  15. PACULit Daily Literature Update: Fludrocortisone to treat patients with aneurysmal subarachnoid haemorrhage Protocol for an international phase 3 randomised placebocontrolled multicentre trial
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  16. PACULit Daily Literature Update: Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest
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  17. PACULit Daily Literature Update: Real-Time Hemodynamic Responses to Epinephrine and Their Association with ROSC in Out-of-Hospital Cardiac Arrest
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  18. Reevaluating bicarbonate therapy in pediatric DKA A propensity scorematched analysis of neurological and respiratory outcomes
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  19. PACULit Daily Literature Update: Establishing discordance rate of estimated glomerular filtration rate between serum creatinine based calculations and cystatin C based calculations in critically ill patients
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  20. Alteplase for Posterior Circulation Ischemic Stroke at 45 to 24 Hours
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  21. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
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  22. ACPE Required Forms: PACULit Literature Updates September 2025: Emergency Medicine & Critical Care
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Daily Literature Update

Evaluation of Etomidate Use and Association with Mortality Compared with Ketamine among Critically Ill Patients

Wunsch H, Bosch NA, Law AC, Vail EA, Hua M, Shen BH, Lindenauer PK, Juurlink DN, Walkey AJ, Gershengorn HB. Evaluation of Etomidate Use and Association with Mortality Compared with Ketamine among Critically Ill Patients. Am J Respir Crit Care Med. 2024 Nov 15;210(10):1243-1251. doi: 10.1164/rccm.202404-0813OC. PMID: 39173173.

Study Type: Retrospective observational cohort study with propensity score matching

Population: Critically ill adults receiving invasive mechanical ventilation (IMV) in ICUs (n=1,689,945; matched subset n=44,546)

Intervention: Receipt of etomidate on day of IMV initiation versus ketamine

Outcomes: Hospital mortality; effect modification by post-intubation corticosteroid use

Key Findings

  • 43.7% of patients receiving IMV received etomidate.
  • In matched analysis, etomidate was associated with higher hospital mortality vs ketamine (21.6% vs 18.7%), absolute risk difference 2.8% (95% CI 2.13.6%), adjusted OR 1.28 (95% CI 1.211.34).
  • Findings were consistent across subgroups and sensitivity analyses.
  • Post-intubation corticosteroid administration did not reduce increased mortality risk associated with etomidate.
  • Systematic review & meta-analysis, 2025: No 30-day survival difference etomidate vs ketamine; etomidate linked to adrenal insufficiency; ketamine increased vasopressor needs. (PMID: 40239104)
  • Meta-analysis of RCTs: Etomidate increased mortality vs other agents; risk ratio 1.16 (95% CI 1.011.33; P=0.03). (PMID: 37127020)
  • Bayesian meta-analysis: Ketamine associated with moderate probability (83.2%) of improved survival in critically ill patients. (PMID: 38368326)
  • Background source: Adrenal suppression risk with etomidate and hemodynamic stability facts. (Wikipedia)

Strengths & Limitations

Strengths Limitations
Very large ICU cohort from Premier Healthcare Database (1.7 million patients) Observational design, cannot prove causality
Propensity score matching to balance confounders Potential unmeasured confounding (e.g., illness severity scores not included)
Consistent findings across multiple sensitivity and subgroup analyses Limited info on timing/doses of corticosteroids and vasopressors

Clinical Implications & Impact

Pharmacists should weigh risks of etomidate-related adrenal suppression and increased mortality against ketamine9s hemodynamic effects in RSI for critically ill patients. Consideration of alternative induction agents may improve hospital survival outcomes. Post-intubation corticosteroid administration does not mitigate etomidate9s mortality risk. Close monitoring for adrenal insufficiency and hemodynamic instability remains essential.

Conclusion

In a large ICU cohort, use of etomidate on the day of invasive mechanical ventilation was associated with increased hospital mortality compared with ketamine, independent of corticosteroid treatment.

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Citations

  • Wunsch H et al. Am J Respir Crit Care Med. 2024;210(10):1243-1251. PMID:39173173
  • Systematic review & meta-analysis. 2025. PMID:40239104
  • Meta-analysis of RCTs. 2023. PMID:37127020
  • Bayesian meta-analysis. 2023. PMID:38368326
  • Wikipedia contributors. Etomidate. Accessed 2024.

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