Special K – time for a reappraisal ?

2 recent articles highlight the potential benefit of an often overlooked induction agent in critically ill patients.

Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Jabre, P. et al. Lancet. Volume 374, Issue 9686, Pages 293 – 300, 25 July 2009.

This multicentre, randomised, blinded trial in 65 french ICUs & 12 field teams enrolled 655 patients to either etomidate or ketamine for emergent intubation for critical illness. Patients were analysed only if they remained in ICU after day 3 (469). Adequate and reasonable power calculation, including predetermined septic & trauma subgroups. Primary end point was maximal SOFA score within 3 days (chosen as etomidate’s effects on adrenocortical axis thought to last <48 hrs). Secondary end points included intubation conditions, and 28 day ICU stay, catecholamine requirement, mortality & adrenocortical insufficiency.

Use of Polyclonal Ig as Adjuvant Therapy for Sepsis/Severe Sepsis K Georg. Kreymann et al CCM 2007 35(12) 2677-

This important paper is a meta analysis of all trials including the use of IVIG in patients (adult and Children-including neonates) with sepsis and severe sepsis. IVIG bind up toxins, allow oponisation and bind toxins and superantigens Previous papers from the Cochrane group have apparently not included all studies which this meta analysis has tried to do.
The search criteria was vigorous, including peer reviewed articles as well as personal communications, letters etc. They particularly included studies which used mortality as an end point. They graded papers on strict guidelines as there was a paucity of double blinded randomised placebo controlled trials (DBRPCT) to try and add some power to the meta analysis.

In all 27 trials were included. In 15 trials, including 1492 patients (adults and children) showed the use of IVIG created a RR of 0.79 (significant). When split into type of IVIG, the IVIGAM (immunoglobulins containing predominantly IVIG A and M) were used in 560 patients with a significant RR of 0.66. With just IVIG, including 932 patients, RR was 0.85 (significant). IVIG A and M showed further benefit over just IVIG. It is interesting to note many studies showed a positive trend but these trials were rated as significantly heterogeneous on tests. The largest trial showed no difference between those treated with IVIG and these not. 12 trials included neonates and are not discussed further here.