KETAMINE ISN’T HAEMODYNAMICALLY NEUTRAL - but neither is anything really...

ROCKET PR
55 minutes ago
2 min read

Author: Kaleb Lachenicht, Chief Clinical Officer of ROCKET and Director Epic EM

What should we learn from the latest evidence on induction agents?

This 2026 systematic review and network meta-analysis compared ketamine, etomidate, propofol and ketofol for emergency tracheal intubation in critically ill adults.

9 RCTs | 4,672 patients

The important finding for retrieval clinicians is not that we have found a new “best” induction drug.

It is that the idea of a haemodynamically safe induction drug is probably the wrong way to think about RSI.

KETAMINE vs ETOMIDATE

There was no convincing mortality difference between ketamine and etomidate.

But ketamine was associated with:

↑ Cardiovascular collapse — OR 1.44
↑ Post-induction hypotension — OR 1.34
↑ Peri-intubation vasopressor use — OR 1.45
No meaningful difference in first-pass success
No clear difference in peri-intubation cardiac arrest

The message is NOT:

“Stop using ketamine.”

The message is:

Stop assuming ketamine will protect the circulation.

WHY CAN KETAMINE DROP THE BP?

THE DRUG IS ONLY PART OF THE RSI

Remember what happens around induction:

Loss of sympathetic drive ↓ Loss of vascular tone / myocardial compensation ↓ Positive-pressure ventilation ↓ ↑ Intrathoracic pressure ↓ ↓ Venous return / RV preload ↓

CARDIOVASCULAR COLLAPSE

This is why changing the induction agent alone cannot make a physiologically dangerous intubation safe.

DOSE MATTERS

An important limitation of the evidence in this review:

Many trials used ketamine doses around 1–2 mg/kg

That may be very different from how we approach the profoundly unstable retrieval patient, a shocked 80-kg patient does not necessarily require the same induction dose as a physiologically normal 80-kg patient. Dosing for the unstable patient probably lies closer to the 0.5-1mg/kg range.

Drug choice matters. Dose matters too.

BEFORE YOU PUSH THE DRUG…

For the haemodynamically fragile patient, ask:

THE BOTTOM LINE

There is probably no haemodynamically “safe” induction drug.

Ketamine remains an extremely useful induction agent.

But: Ketamine ≠ haemodynamic protection.

The safest RSI comes from recognising the physiology, resuscitating where possible, choosing and dosing the induction agent intelligently, anticipating the effect of positive pressure, and having haemodynamic rescue ready before induction.

The question is not

“Which induction drug should I use?”

The better question is:

“What is keeping this patient alive, and how will I maintain it?”

Reference

Zampieri, F.G. et al. (2026) ‘Induction agents for emergency tracheal intubation in critically ill adults: a systematic review and network meta-analysis’, Critical Care. doi:10.1186/s13054-026-06067-w.