Effect of Subarachnoid Anesthesia Combined with Propofol TCI on THA

0
0
0

Effect of Subarachnoid Anesthesia Combined with Propofol Target-Controlled Infusion on Blood Loss and Transfusion for Posterior Total Hip Arthroplasty in Elderly Patients

Total hip arthroplasty (THA) is a common surgical procedure for elderly patients, particularly via the posterior approach. However, perioperative blood loss and the need for transfusion remain significant challenges. This study evaluated the efficacy of subarachnoid anesthesia combined with propofol target-controlled infusion (TCI) in reducing blood loss and transfusion requirements compared to combined spinal-epidural anesthesia (CSEA) and general anesthesia (GA). The trial aimed to address gaps in existing anesthesia practices by proposing a novel approach that optimizes hemodynamic stability while minimizing complications.

Study Design and Participant Selection

The randomized controlled trial enrolled 240 patients aged ≥65 years (American Society of Anesthesiologists [ASA] physical status I–III) scheduled for posterior THA. Participants were divided into three groups: Group C (CSEA, n = 80), Group G (GA, n = 80), and Group T (subarachnoid anesthesia + propofol TCI, n = 80). Exclusion criteria included severe hypertension, coagulation disorders, hematologic diseases, or recent NSAID use. Sample size calculations were based on a pilot trial, with at least 74 patients per group required to detect significant differences in blood loss (α = 0.05, power = 0.8).

Anesthesia Techniques

Group C (CSEA): Patients received spinal anesthesia using 2.5 mL 0.5% ropivacaine at the L2/3 or L3/4 interspace, followed by epidural catheter placement. Sedation with midazolam (2 mg) was administered if required.
Group G (GA): Total intravenous anesthesia was induced with midazolam, sulfentanyl, propofol, and rocuronium, followed by tracheal intubation. Anesthesia was maintained using propofol (4–12 mg/kg/h) and remifentanil (0.2–0.25 mg/kg/min), with controlled hypotension achieved via esmolol and isosorbide dinitrate.
Group T (Subarachnoid anesthesia + TCI): Subarachnoid anesthesia was administered using 2.5 mL 0.5% ropivacaine, followed by propofol TCI titrated to maintain unconsciousness (target concentration: 1.0–1.5 mg/mL). Hemodynamic stability was prioritized, with ephedrine used for hypotension (MAP <60 mmHg).

Primary Outcomes: Blood Loss and Transfusion

Intraoperative blood loss in Group C (455.40 ± 120.48 mL) was significantly higher than in Group G (308.03 ± 64.90 mL) and Group T (331.53 ± 64.33 mL) (F = 65.80, P < 0.001). Autologous transfusion volumes followed a similar pattern: Group C (178.31 ± 48.68 mL) required more blood salvage than Group G (124.09 ± 24.34 mL) and Group T (130.99 ± 31.36 mL) (F = 52.99, P < 0.001). Allogeneic transfusion rates were higher in Group C (median [IQR]: 0 [0, 100.00 mL]) compared to Groups G and T (0 mL for both; Z = 2.47, P = 0.047).

Hemodynamic Stability

Mean arterial pressure (MAP) variations revealed critical differences:

  • Baseline MAP: Comparable across groups (~98–101 mmHg).
  • Intraoperative MAP: Group C maintained higher MAP (97.16–107.14 mmHg) versus Group G (65.44–109.49 mmHg) and Group T (63.29–101.00 mmHg). Group T achieved the lowest MAP during surgery (F = 559.89, P < 0.001 at 30 minutes), attributable to sympathetic blockade from spinal anesthesia and propofol-induced vasodilation.
  • Controlled Hypothension: Group G required vasoactive agents to reduce MAP by 30% from baseline, whereas Group T achieved stable hypotension without excessive pharmacologic intervention.

Secondary Outcomes

PACU Stay: Group T (9.41 ± 1.19 minutes) and Group C (8.83 ± 1.26 minutes) had shorter PACU stays than Group G (16.55 ± 3.10 minutes; F = 352.50, P < 0.001), reflecting faster recovery from spinal anesthesia and TCI compared to GA.
Hospitalization and Pain Scores: No differences were observed in hospital stay length (4–4.3 days) or postoperative VAS pain scores (~3.4–3.5/10).
Patient Satisfaction: Group T had higher satisfaction rates (77/80, 96.3%) than Group C (66/80, 82.5%; χ² = 7.96, P = 0.004) and Group G (69/80, 86.3%; χ² = 5.01, P = 0.025).

Complications

  • Group C: 1 patient reported post-dural puncture headache (PDPH); 2 reported low back pain.
  • Group G: Higher incidence of postoperative nausea and vomiting (PONV, 10/80 vs. 3/80 in Group T; χ² = 4.10, P = 0.043) and throat discomfort (13.8%).
  • Group T: No PDPH, lower back pain, or PONV. No cases of deep vein thrombosis (DVT) or delayed rehabilitation occurred in any group.

Discussion of Mechanisms and Advantages

The superior outcomes in Group T stem from synergistic effects of subarachnoid anesthesia and propofol TCI. Spinal anesthesia provided dense sensory blockade, reducing nociceptive stimulation, while propofol TCI enabled precise control of sedation depth, minimizing hemodynamic fluctuations. This combination avoided the pitfalls of CSEA (e.g., higher MAP, PDPH risk from epidural needles) and GA (e.g., PONV, prolonged recovery). Controlled hypotension in Group T was achieved more physiologically, reducing reliance on vasodilators.

Clinical Implications

For elderly patients undergoing THA, subarachnoid anesthesia with propofol TCI offers a balanced approach:

  1. Reduced Blood Loss: Lower intraoperative MAP decreases surgical bleeding.
  2. Faster Recovery: Shorter PACU stays align with enhanced recovery protocols.
  3. Fewer Complications: Absence of PDPH, PONV, and airway trauma improves patient experience.
  4. Cost-Effectiveness: Lower transfusion requirements and reduced PACU time may lower healthcare costs.

Limitations and Future Directions

The study’s single-center design and lack of long-term follow-up limit generalizability. Future research should compare TCI with other sedation regimens (e.g., dexmedetomidine) and assess outcomes like cognitive function or mortality.

doi.org/10.1097/CM9.0000000000000688

Was this helpful?

0 / 0