Navigating Anesthetic Induction in Critically Ill Patients: Insights on Intubation and Hemodynamics

A systematic review of induction-agent evidence clarifies how choice of drug alters intubating conditions and cardiovascular risk in critically ill adults.

The review found that etomidate was frequently used and consistently associated with relative hemodynamic stability compared with alternatives in the included studies. This pattern was most evident in patients with limited cardiovascular reserve—those who are hemodynamically unstable, in septic shock, or undergoing emergent intubation in the emergency department or ICU—where preserving blood pressure during induction is a priority.

Notably, the review emphasizes a consistent tradeoff: while etomidate preserves short-term hemodynamics, it carries a measurable risk of adrenal suppression that must be weighed in patients at high risk for adrenal insufficiency.

Reported incidence of post-induction hypotension varied widely across studies, ranging from 6% to 84% depending on definition, timing window, and patient mix. Heterogeneity in hypotension definitions, observation periods, baseline patient severity, and concomitant vasoactive support produces much of this numeric span, limiting head-to-head comparisons between agents.