Induction strategies for preventing hemodynamic changes after intubation in non-cardiac surgery patients: a network meta-analysis of randomized controlled trials

Background: Tracheal intubation and laryngoscopy during general anesthesia induce significant hemodynamic changes. Although generally transient, these physiological perturbations may precipitate critical cardiovascular events in high-risk populations. Anesthesiologists have used various drug combinations to suppress this response. This network meta-analysis (NMA) aimed to identify a drug combination that can better suppress hemodynamic fluctuations caused by tracheal intubation in non-cardiac surgical patients. Methods: We searched 3 different medical literature databases. A NMA was performed on the included randomized controlled trials (RCTs). RCTs were evaluated using the Cochrane risk of bias tool. A random effects network meta-analysis was performed within a frequentist framework. The effects of each pharmacological strategy on intraoperative hemodynamics in patients undergoing non-cardiac surgery were compared. Endpoints included ΔMean Arterial Pressure (ΔMAP) and ΔHeart Rate (ΔHR). Results: The network meta-analysis included 10 studies and 791 patients. According to the surface under the cumulative ranking curve, Oxycodone-Propofol-Lidocaine (87.4%) demonstrated superior efficacy in controlling fluctuations in MAP, followed by Fentanyl-Propofol-Dexmedetomidine (82.9%) and Fentanyl-Propofol-Clonidine (81.6%). Fen-Pro-Dex (94.8%) demonstrated superior efficacy in controlling fluctuations in HR, followed by Fentanyl-Propofol-Lidocaine (Epidural) (83.3%), Fentanyl-Propofol-Remifentanil (79.1%). Conclusion: Among patients undergoing non-cardiac surgery, Oxy-Pro-Lid was preferred for attenuating post-intubation changes in MAP, whereas Fen-Pro-Dex provided superior control of HR fluctuations. These findings may help guide the selection of induction pharmacological strategies, although more randomized controlled trials are needed to confirm these results and clarify optimal dosing. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024591333, identifier CRD42024591333.