A 58-year-old male with severe hypertension (BP 180/110 mmHg), coronary artery disease, and ejection fraction of 35% is scheduled for emergency laparoscopic cholecystectomy. During induction, which IV agent should be avoided and what is the most appropriate alternative?

Explanation

## Clinical Context A patient with severe hypertension, CAD, and reduced ejection fraction requires careful agent selection. Propofol causes profound vasodilation and myocardial depression, which is contraindicated in this haemodynamically unstable patient. ## Why Etomidate is Preferred **Key Point:** Etomidate maintains cardiovascular stability through preserved sympathetic tone and baroreceptor reflexes, making it the agent of choice in haemodynamically compromised patients. **High-Yield:** Etomidate is the gold standard induction agent in: - Cardiogenic shock - Severe hypertension with cardiac disease - Septic shock - Hypovolaemia ## Comparison of IV Induction Agents in Cardiac Compromise | Agent | Cardiovascular Effect | Myocardial Depression | Use in Cardiac Disease | |-------|----------------------|----------------------|------------------------| | **Propofol** | ↓↓ BP, ↓ SVR | Marked | Contraindicated | | **Thiopentone** | ↓↓ BP | Moderate-marked | Avoid | | **Etomidate** | Minimal change | Minimal | **Preferred** | | **Ketamine** | ↑ BP, ↑ HR | Minimal | Good alternative | **Clinical Pearl:** In this patient, etomidate's preservation of airway reflexes and lack of respiratory depression are additional advantages, though adrenocortical suppression with single dose is clinically insignificant in acute settings. **Warning:** Do not confuse etomidate's stability with lack of side effects—it causes adrenal suppression (though single-dose effect is debated) and pain on injection.