Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?

Zacchary Tamsett; Ned Douglas; Cathy King; Tanya Johnston; Connor Bentley; Brian Hao; Duron Prinsloo; Elyssia M Bourke

doi:10.1111/1742-6723.14355

Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?

Emerg Med Australas. 2023 Nov 29. doi: 10.1111/1742-6723.14355. Online ahead of print.

Authors

Zacchary Tamsett¹, Ned Douglas^{2

3}, Cathy King^{1

4}, Tanya Johnston¹, Connor Bentley¹, Brian Hao¹, Duron Prinsloo¹, Elyssia M Bourke^{1

3

5}

Affiliations

¹ Department of Emergency Medicine, Grampians Health, Ballarat, Victoria, Australia.
² Department of Anaesthesia, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
³ Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.
⁴ School of Medicine, Deakin University, Geelong, Victoria, Australia.
⁵ Department of Emergency Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.

PMID: 38018391
DOI: 10.1111/1742-6723.14355

Abstract

Objective: To describe the effects of different induction agents on the incidence of post-induction hypotension (PIH) and its associated interventions during rapid sequence intubation (RSI) in the ED.

Methods: A single centre retrospective study of patients intubated between 2018 and 2021 was conducted in a regional Australian ED. The impact of induction agent choice, in addition to demographic and clinical factors on the incidence of PIH were determined using descriptive statistics and a multivariate analysis presented as adjusted odds ratios (aORs) and their 95% confidence intervals (CIs).

Results: Ketamine and propofol, used either individually or in conjunction with fentanyl, were significantly associated with PIH (ketamine aOR 4.5, 95% CI 1.35-14.96; propofol aOR 4.88, 95% CI 1.46-16.29). Age >60 years was associated with a greater requirement for vasopressors (aOR 4.46, 95% CI 2.49-7.97) and a higher risk of mortality after RSI (aOR 4.2, 95% CI 1.87-9.40). Patients with a shock index >1.0 were significantly more likely to require vasopressors (aOR 5.13, 95% CI 2.35-11.2) and have a cardiac arrest within 15 min of RSI (aOR 3.56, 95% CI 1.07-11.8).

Conclusions: Exposure to both propofol and ketamine is significantly associated with PIH after RSI, alongside age and shock index. PIH is likely multifactorial in nature, and this data supports the sympatholytic effect of induction agents as the underlying cause of PIH rather than the choice of agent itself. Further prospective work including a randomised controlled trial between induction agents is justified to further clarify this important clinical question.

Keywords: anaesthetic morbidity; induction agents; post-induction hypotension; rapid sequence intubation.