Hemodynamic Responses to Alternative Induction Protocols in High-Risk Surgical Patients

Induction of general anesthesia in hemodynamically fragile patients — those with depressed ventricular function, uncontrolled hypertension, advanced age, or septic physiology — exposes the trade-off between an agent's sedative reliability and its cardiovascular cost more acutely than almost any other moment in the perioperative course. This review synthesizes comparative and meta-analytic evidence on alternative induction protocols in these high-risk populations, focusing on etomidate, ketamine and ketamine-propofol combinations, esketamine as a hemodynamic buffer, and remimazolam as an emerging alternative to propofol. In cardiac surgical patients with depressed left ventricular function, etomidate's traditional hemodynamic advantage over propofol-based combinations has narrowed as trials show ketamine-propofol and propofol-etomidate regimens achieving comparable stability without etomidate's adrenocortical suppression. In critically ill and septic patients, network meta-analyses and randomized trials now position ketamine as hemodynamically comparable to etomidate without a demonstrated mortality penalty for either agent, while remimazolam has accumulated consistent randomized evidence for superior hemodynamic stability over propofol in hypertensive, elderly, and cardiac surgical populations. We conclude that no single agent is a universal solution, and that matching induction strategy to the specific physiologic vulnerability at hand, rather than applying a fixed protocol, is what the comparative literature actually supports.