Association of Induction Agent Choice With Early Mortality and Prognostic Outcomes in Critically Ill Patients: A Large-Scale Retrospective Cohort Analysis

Endotracheal intubation is an accepted procedure to optimize oxygenation and ventilation and reduce the risk of aspiration for critically ill patients, essential for their management and survival across various settings, including prehospital care, emergency departments (EDs), and intensive care units (ICUs). Despite advancements, peri-intubation complications and hemodynamic instability, which are associated with increased mortality rates, remain a concern. These risks are exacerbated by pathophysiological factors in critically ill patients compared to those undergoing intubation in surgical settings .

A recent international, multicentre, prospective cohort (INTUBE) study of 2964 critically ill patients undergoing tracheal intubation in the ICU, emergency department, or inpatient wards in 29 countries across five continents reported that the most frequently used agents for induction were Propofol (41.5%), Midazolam (36.4%), Etomidate (17.8%), and Ketamine (14.2%).

The choice of induction agent for intubation may have the potential to minimise or exacerbate complication and mortality. Although considerable research has been carried out, critical central question concern which induction agent is most effective in minimizing cardiovascular instability during intubation. As Kotani and Risotto declared in their recent systematic review, the available findings are insufficient to support conclusive statements. Further studies are needed to identify the optimal agent and dosage, taking into account patient variability and concurrent therapeutic interventions.

Understanding the impact of induction agent selection in critically ill patients has the potential to guide clinical practice in emergency and intensive care settings. Identifying agents with improved survival and prognosis would optimize patient management and inform decision-making for airway management in this vulnerable population. Moreover, delineating which agents exert minimal adverse effects on mortality and prognosis may provide valuable insight for anesthesiologists, intensivists, emergency medicine physicians, and trauma physicians.