The RSI Trial
Practical Applications in Clinical Practice
1. No Mortality Benefit
The trial found no statistically significant difference in 28-day in-hospital mortality between ketamine (28.1%) and etomidate (29.1%) groups (adjusted risk difference −0.8%, 95% CI −4.5 to 2.9; P = 0.65).
Implication: Either agent may be appropriate from a mortality standpoint, allowing clinicians to prioritize other patient-specific factors.
2. Risk Stratification
Cardiovascular collapse during intubation was significantly more common with ketamine (22.1%) vs etomidate (17.0%) — adjusted risk difference +5.1%, 95% CI 1.9 to 8.3.
The effect was more pronounced in septic patients (30.6% vs. 20.9%) and those with high APACHE II scores ≥20 (31.4% vs. 20.7%).
Implication: Exercise caution when using ketamine in hemodynamically fragile patients.
3. Contextualized Approach to Induction Agents
Despite ketamine's theoretical advantage of supporting blood pressure via catecholamine release, its negative inotropic and vasodilatory effects may dominate in critically ill populations.
Implication: Tailor induction drug choice based on patient’s physiology, not solely on generalized assumptions (e.g., ketamine is not always hemodynamically superior).