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Etomidate and Ciprofol for Induction in CABG Under Cardiopulmonary Bypass: Mechanistic Rationale, Evidence Gaps, and
Yi-Nan Li1, Qian Yang2, Li-Xian He2
1Department of Anesthesiology, Dali University, Dali, Yunnan, China; Department of Anesthesiology, Fuwai Yunnan Hospital, Chinese Academy of Medical Sciences, Affiliated Cardiovascular Hospital of Kunming Medical University, Kunming, Yunnan, China.
Insights
Choosing between etomidate and ciprofol for anesthesia in coronary artery bypass grafting (CABG) surgery is crucial. Current evidence does not prove which agent better prevents acute kidney injury (AKI) or postoperative delirium (POD) in these high-risk patients.
Area of Science:
- Anesthesiology
- Cardiovascular Surgery
- Critical Care Medicine
Background:
- Coronary artery bypass grafting (CABG) patients face significant perioperative stress, increasing risks of acute kidney injury (AKI) and postoperative delirium (POD).
- Anesthetic induction impacts hemodynamic stability, cerebral oxygenation, and tissue perfusion during cardiopulmonary bypass (CPB).
- Etomidate offers hemodynamic stability but suppresses the cortisol stress response; ciprofol shows promise but lacks direct comparison for organ outcomes in CABG.
Purpose of the Study:
- To review the mechanistic rationale and evidence gaps comparing etomidate and ciprofol for anesthesia in CABG patients.
- To propose standardized design considerations for future randomized trials on etomidate versus ciprofol in CABG.
- To construct testable hypotheses for future research on anesthetic agents and organ protection in CABG.
Main Methods:
- This is a narrative review summarizing existing literature and mechanistic insights.
- It identifies evidence gaps regarding the comparative efficacy of etomidate and ciprofol for AKI and POD.
- It proposes standardized trial design elements, including outcome measures and covariate control.
Main Results:
- No randomized trials directly compare etomidate and ciprofol using AKI or POD as primary outcomes in CABG patients.
- The superiority of either anesthetic agent for preventing organ dysfunction in this population remains unproven.
- Mechanistic considerations suggest potential differential effects on stress response and organ perfusion.
Conclusions:
- High-quality randomized trials are needed to compare etomidate and ciprofol in CABG patients, focusing on AKI and POD.
- Standardized methodologies, including validated criteria for AKI and delirium assessment, are essential for future research.
- Optimizing anesthetic choice requires evidence-based understanding of organ protection strategies in high-risk surgical populations.
Abstract:
Patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) are exposed to substantial perioperative stress, inflammation, and perfusion vulnerability, which may increase the risk of postoperative acute kidney injury (AKI) and postoperative delirium (POD). Although anesthesia induction is brief, it can influence blood pressure, vascular responsiveness, vasopressor exposure, cerebral oxygenation, and tissue perfusion. Etomidate is widely used in high-risk patients because of its hemodynamic stability, but it inhibits adrenal 11β-hydroxylase and attenuates the cortisol stress response. Ciprofol, a newer intravenous anesthetic, has shown favorable induction hemodynamics and less injection pain in some studies; however, current evidence largely comes from propofol comparisons, non-CABG populations, or process outcomes. No randomized evidence directly compares ciprofol with etomidate in adults undergoing CABG with CPB using AKI or POD as core outcomes. Thus, the superiority of either agent for organ outcomes is unproven. This narrative review summarizes the mechanistic rationale and evidence gaps and proposes standardized design considerations for future high-quality clinical trials. Future studies should use standardized Kidney Disease: Improving Global Outcomes AKI criteria and Confusion Assessment Method (CAM) or CAM‒intensive care unit delirium assessment while controlling CPB management, transfusion, vasopressor use, sedation, analgesia, and perioperative steroid exposure. This review aims to construct testable clinical hypotheses and provide a rationale for future trials, rather than to determine the absolute clinical superiority of either agent.
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