Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis

BACKGROUND

Tracheal intubation is a high-risk intervention commonly performed in critically ill patients. Due to its favorable cardiovascular profile, ketamine is considered less likely to compromise clinical outcomes. This meta-analysis aimed to assess whether ketamine, compared with other agents, reduces mortality in critically ill patients undergoing intubation.

METHODS

We searched MEDLINE, Embase, and the Cochrane Library from inception until April 27, 2023, for randomized controlled trials and matched observational studies comparing ketamine with any control in critically ill patients as an induction agent. The primary outcome was mortality at the longest follow-up available, and the secondary outcomes included Sequential Organ Failure Assessment score, ventilator-free days at day 28, vasopressor-free days at day 28, post-induction mean arterial pressure, and successful intubation on the first attempt. For the primary outcome, we used a Bayesian random-effects meta-analysis on the risk ratio (RR) scale with a weakly informative neutral prior corresponding to a mean estimate of no difference with 95% probability; the estimated effect size will fall between a relative risk of 0.25 and 4. The RR and 95% credible interval (CrI) were used to estimate the probability of mortality reduction (RR < 1). The secondary outcomes were assessed with a frequentist random-effects model. We registered this study in Open Science Framework ( https://osf.io/2vf79/ ).

RESULTS

We included seven randomized trials and one propensity-matched study totaling 2978 patients. Etomidate was the comparator in all the identified studies. The probability that ketamine reduced mortality was 83.2% (376/1475 [25%] vs. 411/1503 [27%]; RR, 0.93; 95% CrI, 0.79-1.08), which was confirmed by a subgroup analysis excluding studies with a high risk of bias. No significant difference was observed in any secondary outcomes.

CONCLUSIONS

All of the included studies evaluated ketamine versus etomidate among critically ill adults requiring tracheal intubation. This meta-analysis showed a moderate probability that induction with ketamine is associated with a reduced risk of mortality.

The first nurse practitioner graduate programme in Japan

Aim

This paper describes the establishment of the first Japanese nurse practitioner graduate programme and legislative activities to institutionalize nurse practitioners in Japan.

Background

To address the super-ageing population, Oita University of Nursing and Health Sciences initiated the first academic graduate level nurse practitioner programme in Japan, based upon the global standard defined by the International Council of Nurses.

Conclusion

In 2010, Oita University of Nursing and Health Sciences graduated the first nurse practitioner. We believe that nurse practitioners will be highly valued in Japan for thoughtful nursing care to the fragile elders living in rural and urban Japan.

Clinicopathological study on liver dysfunction in measles

We analyzed the clinical course of eight patients with liver dysfunction in measles. All of the patients showed an elevation of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and lactate dehydrogenase (LDH), but no jaundice. These levels returned to normal about 3 weeks after the onset of the rash. A percutaneous liver biopsy was done in two cases. Histological examination showed slight necrosis of liver cells but no significant changes in portal area. On electron microscopy, virus particles were not detected. We detected measles virus RNA in the liver specimen by RT-PCR, which suggests that the measles virus affects liver cells directly in measles.

Osteoblastoma: classification and report of 16 patients

In 16 patients who had osteoblastoma treated within the last eight years, the lesions can be classified as vertebral (four cases), central "benign" (seven cases), "aggressive" (three cases) and periosteal (two cases). The radiographic features were highly variable except for the consistent shell of reactive periosteal bone. None of the lesions resembled osteoid osteoma or osteosarcoma. The histological pattern was typical, showing sheets of osteoblasts forming irregular, poorly ossified bone trabeculae in a fibrovascular stroma. The three "aggressive" lesions had a distinctly more ominous histologic pattern, a more destructive radiographic appearance and recurred promptly following local curettage. Treatment varied, but for the vertebral, benign "central," and periosteal osteoblastomas, curettage or marginal resection was generally curative. Local wide resection was required for individual aggressively growing tumors.