(1631) Association of Induction Agents for Intubation and Outcomes in Sepsis: A Target Trial Emulation

Introduction: Sepsis, a life-threatening organ dysfunction, frequently progresses to shock, often necessitating need for mechanical ventilation. The use of induction agents for endotracheal intubation can have significant hemodynamic effects complicating sepsis management. This study aims to evaluate the influence of different induction medications used for endotracheal intubation in septic shock patients. We hypothesize that induction agents will significantly differ in their impact on hemodynamics and clinical outcomes.

Methods: A retrospective single-center cohort study was conducted evaluating critically ill adult (≥ 18 years) patients with septic shock who underwent endotracheal intubation from January 1, 2006, through January 31, 2022, in the medical intensive care unit of Mayo Clinic Rochester. Patients were divided into five groups based on the choice of agent: etomidate, ketamine, propofol, etomidate+ propofol (EP) and ketamine+ propofol (KP). Hemodynamic and other clinical outcomes were compared between the groups.

Results: Six hundred and twenty-five patients underwent intubation. Propofol was used in 276(44%),147 (24%) received etomidate, 95 (15%) received KP, 70 (11%) received EP, and 37 (6%) received ketamine alone. The least drop in mean arterial pressure or systolic blood pressure (p=0.007) was noted in propofol group (18.1%) compared to etomidate (25.9%) or EP (38.6%) group. In-hospital mortality rates differed significantly (p=0.003): etomidate (43.5%), EP (40.0%), KP (32.6%), ketamine (32.4%), and propofol (25.4%). KP group had the shortest ICU length of stay at 5.003 (2.483-10.434) days (p < 0.001). In the adjusted analysis with inverse probability weighting, propofol (22.567 (0.00-26.311)) was linked to the highest ventilator-free days, and etomidate (10.464(0.00-22.103)) to the lowest (p < 0.001).

Conclusions: The choice of induction agent for mechanically ventilated patients with severe sepsis significantly affects clinical outcomes. Propofol use as the induction agent was associated with better outcomes, including lower in-hospital mortality and more ventilator-free days compared to other agents. Conversely, etomidate was associated with higher in-hospital mortality and more complications. This is a hypothesis generating cohort study and its validity should be evaluated prospectively.