So, the pro arguments for ketamine -
Given your screen name, Im sure you are well aware of ketamine's benefits, so I wont delve too much into those. However, we also know that in the presence of controlled ventilation there is little to no increase in ICP from ketamine. And to be honest, in critically ill patients (who are catecholamine depleted) you are likely to see a hypotensive response after ketamine just as you do the other induction agents, which is probably attributable to the unopposed myocardial depression normally offset by the catechol surge. There is more emerging evidence that ketamine is, in fact, neuroprotective and it is actually becoming more common as a therapy for refractory status epilepticus.
Etomidate - is gross. And you can argue back and forth about the adrenal suppression and increased mortality with its use, but my issues with the drug are more practical. Etomidate is a potent pro-emetic drug. And a lot of these patients remain nauseated for days after a single dose. Though it does not seem to induce seizures, there is definitely a generalized epileptiform discharge on the EEG with its use. And I can even forgive the myoclonus, the long-lasting nausea, the potential adrenal suppression and the literature (albeit very soft) about increased mortality. But to be honest, in my anecdotal experience, I actually see just as much hemodynamic instability with it vs. the other induction agents. And this is in critically ill patients, the population to which this drug is targeted !!
Given your screen name, Im sure you are well aware of ketamine's benefits, so I wont delve too much into those. However, we also know that in the presence of controlled ventilation there is little to no increase in ICP from ketamine. And to be honest, in critically ill patients (who are catecholamine depleted) you are likely to see a hypotensive response after ketamine just as you do the other induction agents, which is probably attributable to the unopposed myocardial depression normally offset by the catechol surge. There is more emerging evidence that ketamine is, in fact, neuroprotective and it is actually becoming more common as a therapy for refractory status epilepticus.
Etomidate - is gross. And you can argue back and forth about the adrenal suppression and increased mortality with its use, but my issues with the drug are more practical. Etomidate is a potent pro-emetic drug. And a lot of these patients remain nauseated for days after a single dose. Though it does not seem to induce seizures, there is definitely a generalized epileptiform discharge on the EEG with its use. And I can even forgive the myoclonus, the long-lasting nausea, the potential adrenal suppression and the literature (albeit very soft) about increased mortality. But to be honest, in my anecdotal experience, I actually see just as much hemodynamic instability with it vs. the other induction agents. And this is in critically ill patients, the population to which this drug is targeted !!
