We would like to thank the reader for their insightful comments [1] on our recent publication, “Hypotension after induction of anesthesia with remimazolam or etomidate: a non-inferiority randomized controlled trial in patients undergoing coronary artery bypass grafting.” Although many previous studies have compared the incidence and severity of hypotension following anesthetic induction with remimazolam versus propofol, limited direct comparisons have been conducted on remimazolam and etomidate, particularly in patients with underlying cardiac disease. Given the widespread use of etomidate in this population, we aimed to address this gap by conducting a non-inferiority randomized controlled trial.

We fully agree with the reader’s point regarding the need for further investigation into the hemodynamic effects of prolonged intraoperative use of remimazolam and its potential neurological outcomes postoperatively. These areas are particularly important in high-risk cardiac surgery populations, and we believe that prospective studies are warranted to establish more robust evidence.

Regarding the issue of blinding [2], we acknowledge that, owing to differences in the physical appearance and volume of the two agents, the anesthesiologist administering the induction drug could not be blinded. However, we used a two-phase approach to achieve a rigorous blinding process. In the first phase, an independent investigator and an attending anesthesiology resident who were not blinded to the group allocation were responsible for preparing and administering the study medication. During this phase, anesthesia was induced according to the allocated group and when the Bispectral Index reached 60, sevoflurane was initiated in both groups. Anesthesia was then maintained using sevoflurane prior to intubation in both groups. The second phase started immediately after endotracheal intubation when a blinded second investigator entered the operating room. The second investigator was responsible for hemodynamic monitoring and vasopressor administration during the first 15 min after endotracheal intubation. Furthermore, the primary outcome analysis was conducted using data collected from an automated vital recording system that continuously recorded hemodynamic parameters throughout the study [3]. To minimize subjective bias, automatically extracted data were analyzed independently by a blinded investigator postoperatively. While complete blinding was not feasible at every level, we made every effort to preserve blinding to ensure the internal validity of our results.

We appreciate the reader’s valuable insights, which highlight important considerations for future research. We hope that this response will clarify the rationale and methodology of our study.