skip to main content

Induction Agent Selection in Heart Failure — FRCA Final MCQ

Instant feedback + full explanation. One question, done properly.

ModerateGeneral AnaesthesiaInduction Agent Selection in Heart FailureFRCA Final

A 72-year-old man with severe chronic heart failure (LVEF 20%, NYHA IV, on maximal medical therapy) and an implantable cardioverter-defibrillator requires emergency laparotomy for bowel obstruction. He has been fluid-resuscitated, is normothermic, and has no clinical evidence of sepsis and no known adrenal disease; invasive arterial monitoring and vasopressors are prepared. A single intravenous induction dose is planned and the priority is to minimise immediate cardiovascular disturbance at induction. Which agent is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Etomidate

Etomidate produces the least immediate haemodynamic disturbance: contractility, heart rate and preload are largely preserved and the UK SmPC describes only a slight, transient fall in peripheral resistance, a profile confirmed in NYHA III–IV patients. A single dose transiently inhibits 11β-hydroxylase, but with no sepsis or adrenal disease and no infusion planned this does not outweigh its haemodynamic advantage. Ketamine is the classic trap: its cardiovascular support is indirect and depends on catecholamine reserve, which is depleted in chronic decompensated failure, so unopposed direct negative inotropy plus increased afterload and myocardial oxygen consumption may precipitate decompensation — the SmPC specifically cautions in congestive heart failure. Propofol and thiopental cause dose-dependent vasodilatation and myocardial depression; midazolam gives slow, unpredictable induction and hypotension, especially with opioids.

Reference: Electronic Medicines Compendium (eMC), Etomidate 2 mg/ml emulsion for injection – Summary of Product Characteristics, sections 4.4/4.5 (current version, accessed 2025): https://www.medicines.org.uk/emc/product/15214/smpc