Post-Intubation Hypotension After Titrated Induction with Ciprofol versus Propofol in Older Adults Undergoing Non-Cardiac Surgery: A Randomized Controlled Trial

Purpose: To compare ciprofol with propofol for titrated induction of anesthesia in older adults undergoing non-cardiac surgery, with a focus on post-intubation hypotension and related hemodynamic burden. Methods: In this prospective, randomized, double-blind trial, adults aged 65– 89 years undergoing elective non-cardiac surgery were randomly assigned in a 1:1 ratio to receive either ciprofol or propofol, following an identical titration-to-effect induction protocol. The primary outcome was post-intubation hypotension, defined as any mean arterial pressure (MAP) ≤ 65 mmHg during the 15-minute period after successful tracheal intubation and before surgical incision. Secondary outcomes included hypotension burden expressed as area under the curve (AUC), norepinephrine requirement, cardiac output trajectories, time to loss of consciousness, and early postoperative recovery outcomes. Results: 160 patients were randomized. Post-intubation hypotension occurred less frequently in the ciprofol group than in the propofol group (28/77 [36.3%] vs 53/79 [67.0%]; adjusted odds ratio 0.28, 95% confidence interval [CI] 0.15– 0.54; P < 0.001), consistent across BIS-adjusted sensitivity analyses. Ciprofol was also associated with a lower AUC for MAP ≤ 65 mmHg (0.0 [0.0– 3.2] vs 2.5 [0.0– 14.8] mmHg min; P = 0.047), reduced norepinephrine requirement (0.0 [0.0– 10.0] μg vs 10.0 [0.0– 20.0] μg; P < 0.001), and milder early cardiac output decline (group-by-time interaction β = − 0.008, 95% CI − 0.010 to − 0.005; P < 0.001). No significant between-group differences were observed in early postoperative adverse outcomes. Conclusion: In this single-center trial of older adults undergoing non-cardiac surgery, ciprofol-based titrated induction was associated with less post-intubation hypotension, lower rescue vasopressor requirement, and less cumulative hypotensive exposure than propofol, without an apparent increase in early adverse recovery outcomes. These findings suggest a favorable hemodynamic profile of ciprofol, which requires confirmation in larger multicenter studies.