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Background: Cardiovascular instability occurring during endotracheal intubation (ETI) in the critically ill is a commonly recognized phenomenon. However, this complication has not been evaluated in terms of the physiological cause (ie, decreased preload, contractility, or afterload) leading to the instability. Thus, the aim of the current investigation was to describe the hemodynamics occurring during ETI with noninvasive physiologic monitoring and to collect preliminary data on the hemodynamic effects of induction agents and positive pressure ventilation. Methods: A multicenter prospective study enrolling adult (≥18 years) critically ill patients undergoing ETI with noninvasive cardiac output monitoring in a medical/surgical intensive care unit from June 2018 to May 2019 was conducted. This study used the Cheetah Medical noninvasive cardiac output monitor to collect hemodynamic data during the peri-intubation period. Additional data collected included baseline characteristics such as illness severity, peri-intubation pharmacologic administration, and mechanical ventilation settings. Results: From the original 27 patients, only 19 (70%) patients had complete data and were included in the final analysis. Propofol was the most common sedative 8 (42%) followed by ketamine 6 (32%) and etomidate 5 (26%). Patients given propofol demonstrated a decrease in total peripheral resistance index (delta change [dynes × s/cm -5 /m 2 ]: -2.7 ± 778.2) but stabilization in cardiac index (delta change (L/min/m 2 ]: 0.1 ± 1.5) while etomidate and ketamine demonstrated increases in total peripheral resistance index (etomidate delta change [dynes × s/cm -5 /m 2 ]: 302.1 ± 414.3; ketamine delta change [dynes × s/cm -5 /m 2 ]: 278.7 ± 418.9) but only etomidate resulted in a decrease in cardiac index (delta change [L/min/m 2 ]: -0.3 ± 0.5). Positive pressure ventilation resulted in minimal changes to hemodynamics during ETI. Conclusions: The current study demonstrates that although propofol administration leads to a decrease in total peripheral resistance index, cardiac index is maintained while etomidate leads to a decrease in cardiac index with both etomidate and ketamine increasing total peripheral resistance index. These hemodynamic profiles are minimally affected by positive pressure ventilation. Study registration: ClinicalTrials.gov ID, NCT03525743., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: NJS is a consultant for Edwards Lifesciences.

Competing Interests: Declaration of competing interest Nathan J. Smischney holds a patent on “KETOFOL” reformulation.

Background: The primary aim of this study was to determine the period prevalence of the single-syringe ketamine-propofol admixture used for sedation and induction among anesthesia providers during a 5-year period before and after educational sessions addressing barriers to its use. Secondary aims were to determine barriers to its use and address the most prevalent concerns through educational sessions., Material and Methods: Surveys were administered to certified and student registered nurse anesthetists, anesthesia residents, and anesthesiologists at Mayo Clinic Rochester, MN before and after educational sessions addressing common barriers. Identified barriers were addressed by oral and/or electronic presentations with identical content., Results: Pre-education period prevalence for sedation was 110 (43%) and 64 (25%) for induction. Identified barriers were uncertainty of benefit in 62 respondents (23%), mixed controlled substance disposal in 48 (18%), regulatory/institutional policies in 20 (7%), and compatibility in 9 (3%). Post-education period prevalence for sedation was 102 (44%), and induction 63 (27%). No concerns were noted in 72% of the post-education group verses 42% in the pre-education group (p<0.01). No concerns were reported in 51% of the electronic only education group verses 64% in the oral education group (p<0.01)., Conclusions: The period prevalence of "ketofol" was greater for sedation than induction. The period prevalence following education showed a slight increase in both sedation and induction use. There was a significant reduction in barriers following education, with oral presentations being more effective than electronic only. Period prevalence was increasing following education; however, allowing more time may have shown a significant practice change.

Background: Endotracheal intubation (ETI) is commonly performed as a life-saving procedure in the intensive care unit (ICU). It is often associated with significant hemodynamic perturbations and can severely impact the outcome of ICU patients. Etomidate is often chosen by many critical care providers for the patients who are hypotensive because of its superior hemodynamic profile compared to other induction medications. However, recent evidence has raised concerns about the increased incidence of adrenal insufficiency and mortality associated with etomidate use. A combination of ketamine and propofol (known as ketofol) has been studied in various settings as an alternative induction agent. In recent years, studies have shown that this combination may provide adequate sedation while maintaining hemodynamic stability, based on the balancing of the hemodynamic effects of these two individual agents. We hypothesized that ketofol may offer a valuable alternative to etomidate in critically ill patients with or without hemodynamic instability., Methods/design: A randomized controlled parallel-group clinical trial of adult critically ill patients admitted to either a medical or surgical ICU at Mayo Clinic in Rochester, MN will be conducted. As part of planned emergency research, informed consent will be waived after appropriate community consultation and notification. Patients undergoing urgent or emergent ETI will receive either etomidate or a 1:1 admixture of ketamine and propofol (ketofol). The primary outcome will be hemodynamic instability during the first 15 minutes following drug administration. Secondary outcomes will include ICU length of stay, mortality, adrenal function, ventilator-free days and vasoactive medication use, among others. The planned sample size is 160 total patients., Discussion: The overall goal of this trial is to assess the hemodynamic consequences of a ketamine-propofol combination used in critically ill patients undergoing urgent or emergent ETI compared to etomidate, a medication with an established hemodynamic profile. The trial will address a crucial gap in the literature regarding the optimal induction agent for ETI in patients that may have potential or established hemodynamic instability. Greater experience with planned emergency research will, hopefully, pave the way for future prospective randomized clinical trials in the critically ill population., Trial Registration: Clinicaltrials.gov: NCT02105415. 31 March 2014.

Background: Endotracheal intubation is a common procedure performed for critically ill patients that can have immediate life-threatening complications. Induction medications are routinely given to facilitate the procedure, but most of these medications are associated with hypotension. While etomidate is known for its neutral hemodynamic profile, it has been linked with increased mortality in septic patients and increased morbidity in trauma patients. Ketamine and propofol are effective anesthetics with counteracting cardiovascular profiles. No data are available about the use of this combination in critically ill patients undergoing endotracheal intubation., Case Report: We describe 6 cases in which the combination of ketamine and propofol ("ketofol") was used as an induction agent for endotracheal intubation in critically ill patients with a focus on hemodynamic outcomes. All patients received a neuromuscular blocker and fentanyl, while 5 patients received midazolam. We recorded mean arterial pressure (MAP) 1 minute before induction and 15 minutes after intubation with the combination. Of the 6 patients, 5 maintained a MAP ≥ 65 mmHg 15 minutes after intubation. One patient was on norepinephrine infusion with a MAP of 64 mmHg, and did not require an increase in the dose of the vasopressor 15 minutes after intubation. No hemodynamic complications were reported after any of the intubations., Conclusions: This case series describes the use of the "ketofol" combination as an induction agent for intubation in critically ill patients when hemodynamic stability is desired. Further research is needed to establish the safety of this combination and how it compares to other induction medications.

Background: Critically ill patients may require emergent intubations, and the use of some induction agents can lead to undesirable effects on hemodynamics. The use of "ketofol" (ketamine/propofol admixture) may allow for improved hemodynamic control. The primary aim of this study was to assess the hemodynamic effects of "ketofol" in a fixed-dose combination during induction of general anesthesia in a controlled environment., Methods: This was a randomized, double-blinded, placebo-controlled trial conducted at the Dartmouth Hitchcock Medical Center. American Society of Anesthesiology physical status I and II patients undergoing general anesthesia were randomly assigned to standardized induction with propofol alone or with "ketofol." Baseline noninvasive hemodynamic measurements were obtained and continuously monitored throughout the study period. Our hypothesis assumed that "ketofol" as an induction alternative would produce stable hemodynamics as referenced from baseline compared with propofol alone. The primary outcome was a systematic randomized assessment of changes in systolic blood pressure from baseline measurements for 30 minutes after induction. The primary comparisons were the frequency of a 20% change in systolic blood pressure at 5 minutes, 10 minutes, and 30 minutes after induction., Results: Baseline patient demographics and intraoperative characteristics were equivalent in both groups. Propofol was more likely to generate a 20% reduction in systolic blood pressure from baseline at 5 minutes (48.8% vs. 12%, odds ratio: 6.87, 95% confidence interval: 2.07-26.15, p = < 0.001) and 10 minutes (67.4% vs. 39%, odds ratio: 3.24, 95% confidence interval: 1.21-8.75, p = < 0.01) as compared with "ketofol." This difference remained significant after adjustment for potentially confounding variables., Conclusion: "Ketofol" is associated with improved hemodynamic stability during the first 10 minutes after induction. Further study is needed to assess the efficacy of "ketofol" in critically ill patients and those with significant comorbidities. This combination has the potential to be used as an alternative agent for emergency induction during which time stable hemodynamics are desirable.

To evaluate the effectiveness of an admixture of ketamine and propofol on peri-induction hemodynamics during airway manipulation, we searched electronic databases of randomized controlled trials from January 1, 2000, to October 17, 2018. Trial screening, selection, and data extraction were done independently by two reviewers with outcomes pooled across included trials using the random-effects model. We included 10 randomized trials (722 patients, mean age of 53.99 years, 39.96% female). American Society of Anesthesiologists physical status was reported in 9 trials with classes I and II representing the majority. Ketamine/propofol admixture was associated with a nonsignificant increase in heart rate (weighted mean difference, 3.36 beats per minute (95% CI, −0.88, 7.60), I2 = 88.6%), a statistically significant increase in systolic blood pressure (weighted mean difference, 9.67 mmHg (95% CI, 1.48, 17.86), I2 = 87.2%), a nonsignificant increase in diastolic blood pressure (weighted mean difference, 2.18 mmHg (95% CI, −2.82, 7.19), I2 = 73.1%), and a nonsignificant increase in mean arterial pressure (weighted mean difference, 3.28 mmHg (95% CI, −0.94, 7.49), I2 = 69.9%) compared to other agents. The risk of bias was high and the certainty of evidence was low. In conclusion, among patients undergoing airway manipulation and needing sedation, the use of a ketamine/propofol admixture may be associated with better hemodynamics compared to nonketamine/propofol sedation. This trial is registered with CRD42019125725. [ABSTRACT FROM AUTHOR]

Objectives: In the last decade, the practice of intubation in the intensive care unit (ICU) has evolved. To further examine the current intubation practice in the ICU, we administered a survey to critical care physicians. Design: Cross-sectional survey study design. Setting: Thirty-two academic/nonacademic centers nationally and internationally. Measurements and Main Results: The survey was developed among a core group of physicians with the assistance of the Survey Research Center at Mayo Clinic, Rochester, Minnesota. The survey was pilot tested for functionality and reliability. The response rate was 82 (51%) of 160 among the 32 centers. Although propofol was the induction drug of choice, there was a significant difference with actual ketamine use and those who indicated a preference for it (ketamine: 52% vs 61%; P < .001). The most common airway device used for intubation was direct laryngoscopy (Miller laryngoscope blade) at 56 (68%) followed by video laryngoscopy at 26 (32%). Most (>90%) indicated that they have a difficult airway cart, but only 55 (67%) indicated they have a documented plan to handle a difficult airway with even lower results for documented review of adverse events (49%). Conclusion: Although propofol was the induction drug of choice, ketamine was a medication that many preferred to use, possibly relating to the fact that the most common complication postintubation is hypotension. Direct laryngoscopy remains the primary airway device for endotracheal intubation. Finally, although the majority stated they had a difficult airway cart available, most did not have a documented plan in place when encountering a difficult airway or a documented process to review adverse events surrounding intubation. [ABSTRACT FROM AUTHOR]