Impact of a BIS-monitored stepwise injection of etomidate for individualized sedation on ERAS in elderly patients with coronary heart disease undergoing thoracoscopic surgery

Introduction: Thoracoscopic surgery in elderly patients with coronary heart disease (CHD) requires careful anesthetic management to maintain hemodynamic stability. While etomidate is valued for its cardiovascular safety, conventional dosing may not provide sufficient individualization. Evidence on the use of bispectral index (BIS)–guided, stepwise etomidate sedation to optimize outcomes and support enhanced recovery after surgery (ERAS) remains limited. Objective: This study assessed the efficacy, safety, and impact on ERAS of a BIS-guided sedation protocol using stepwise etomidate injections in elderly patients with CHD undergoing thoracoscopic surgery. Methods: Ninety patients aged 60–80 years with CHD (classified as American Society of Anesthesiologists physical status I–II) were randomized into three groups (n=30). All received general anesthesia induction with remifentanil through target-controlled infusion plus sevoflurane. The depth of anesthesia was monitored by BIS at thoracic opening and closure. Group I (control) received increased concentrations of sevoflurane; Group II received single intravenous doses of propofol; and Group III received single intravenous doses of etomidate guided by BIS. Hemodynamics, ST-T changes, BIS values, Ramsay sedation scores, post-operative adverse events, and anesthesia costs were compared. Results: Baseline demographics were similar across groups. At thoracic opening and closure, Group I showed higher blood pressure and heart rate than Group II (p<0.05), but was comparable to Group III. Hemodynamic stability was greater in Group III than in Group II (p<0.05). ST-T depression was most severe in Group I and least in Group III. BIS values were higher in Group I, indicating lighter anesthesia. Respiratory depression and dizziness were more frequent in Group II, while nausea, vomiting, and agitation were more common in Group I. Anesthesia costs were highest in Group I. Conclusion: Stepwise etomidate under BIS guidance provides stable hemodynamics, fewer complications, and lower costs, supporting its use in ERAS for elderly CHD patients undergoing thoracoscopic surgery.