Induction drugs for the bleeding patient

There have been a few bleeding patients in recent days. One was a postpartum haemorrhage from an atonic uterus, another was an ectopic pregnancy. I was also part of a clinical meeting discussion about a case of a bleeding gastric ulcer presenting for laparotomy and oversew. The presenter of this case believed that the induction of anaesthesia should be delayed until invasive lines had been placed and until after the patient was resuscitated with fluid and blood. The concern was the patient would "crash" on induction. Presumably this means profound and irreversible hypotension would occur due to the myocardial depressive and vasodilating effects of intravenous anaesthesia. My feeling is that the sooner a bleeding vessel is ligated the better, and I would be keen to get surgery underway ASAP. Lines can be placed later (we know the pressures are low!), the airway of the obtunded patient becomes protected, and we can deal with a still patient much easier than a distressed one. But how do we get to that point without crashing? Propofol with fentanyl or alfentanil are very popular induction drugs, but together they are potent hypotensive agents. They are even more so in the setting of acute hypovolaemia because of the contraction of the central volume. Reich et al in Anesthesia Analgesia Sept 05 identified propofol and fentanyl as drugs that increased the risk of hypotension in older ASA 3+ patients and those with MAP < 70 compared to thiopentone and etomidate. And importantly, induction hypotension was associated with later morbidity and mortality. I have had personal experience with this effect of propofol and fentanyl, and I suspect that the more lipophilic or non-ionised the opioid the greater is the potential hypotensive effect, thus care should be taken with alfentanil and remifentanil as well. So overall, I believe thiopentone (perhaps with a dose as little as 1mg/kg) without opioid is a better choice than propofol for the emergent and unstable bleeding patient needing rapid sequence induction and intubation. The opioid can wait until there is a response to a noxious stimulus.