European Journal of Cardiovascular Medicine

Biological changes that occur with advancing age and an increased susceptibility to complications associated with anaesthesia make Geriatric patients undergoing surgical procedures a particularly difficult demographic to manage [1]. This sensitive population needs anaesthesia to improve results. Inhalational and complete intravenous anaesthesia have been the most popular types of anaesthesia [2]. Because both treatments have pros and cons, making it essential to compare their efficacy and safety specially in Geriatric  surgical patients[3].

Because of changes in pharmacokinetics and pharmacodynamics, TIVA and inhalational anaesthesia must be chosen for surgeries on older people [4]. Because Geriatric   patients organs decreased functions and their bodies don't process medications as well, they may respond differently to anaesthesia [5]. To improve post care for this group, it is important to compare the clinical outcomes of these anaesthetic treatments.

The goal of this study is to find out which is better for Geriatric patients who need surgery: TIVA or inhalational anaesthesia. Clinicians can better help seniors who have had surgery if they know how healing times vary, how common delirium is after surgery, and how common complications are overall.

Objective

• To compare the incidence of postoperative delirium between geriatric patients receiving TIVA and inhalational anaesthesia.
• To evaluate the recovery time and emergence from anesthesia in the two anesthesia groups.
• To assess the impact of anesthesia method on postoperative cognitive function in geriatric surgical patients.
• To analyze the overall complication rates, including cardiovascular events, respiratory complications, and surgical site infections, associated with TIVA versus inhalational anesthesia in the geriatric population.

Overview of Anesthesia Techniques in Geriatric Patients:

Physiological changes that come with Geriatric Patients, diseases, and drug metabolism make things more difficult for anesthesiologists who work with Geriatric Patients who need surgery[6]. This group gets anaesthesia to help them heal faster and avoid problems during the surgery. There are perfect situations for surgery. Inhalational sedation and complete intravenous anaesthesia are frequent for older patients [7].

Figure 1 Total intravenous Anaesthesia(source:[8])

Total Intravenous Anaesthesia (TIVA) uses propofol and opioids to produce and maintain anaesthesia during surgery. Transcutaneous intravenous sedation improves postoperative vomiting and nausea, anaesthesia depth management, and recovery time. TIVA reduces inhalational drug side effects and improves organ function in older people [9].

Inhalational anaesthesia uses a customised breathing circuit to inhale sevoflurane or desflurane. Low hepatic and renal metabolism, fast onset and offset, and easy titration are benefits of inhalational drugs. The consequences on geriatric hemodynamic stability, cognitive function, and anaesthesia emergence are concerning [10].

TIVA and inhalational anaesthesia for Geriatric surgical patients have been compared in numerous trials. These studies used retrospective analysis, prospective cohort studies, and randomised controlled trials. Some studies have demonstrated no difference in clinical results between TIVA and inhalational anaesthesia, while others have suggested that one may be superior for certain patients or surgeries.

In a meta-analysis of elder abdominal surgery patients, [11] found that TIVA reduced cognitive impairment and emergence times compared to inhalational anaesthesia. In a retrospective investigation of senior hip fracture patients, [12] observed no significant difference between TIVA and inhalational anaesthesia.

The literature on geriatric surgical patients shows conflicting results for TIVA and inhalational anaesthesia. Some research suggest one strategy is better, while others show similar results. Existing data gaps include study demographic disparities, anaesthetic procedures, and outcome measures.TIVA and inhaled anaesthesia must be compared in standardised prospective trials in distinct geriatric surgical populations. Senior patients' recovery, postoperative cognitive function, patient satisfaction, and anaesthesia techniques' long-term effects need further study. Filling these literature gaps will help determine the optimum anaesthesia management for this vulnerable population.

Study Design

In elderly patients undergoing surgical procedures, the intention of this retrospective study is to compare the effectiveness of total intravenous anaesthesia (TIVA) and inhalational anaesthesia. In order to investigate sizable patient cohorts over an extended period of time in an efficient manner, retrospective studies analyse data collected for objectives unrelated to the current inquiry.

Inclusion and Exclusion Criteria

Inclusion Criteria

• Individuals who wish to undergo elective surgical procedures must be at least 65 years old.
• Individuals who will be undergoing surgical procedures under inhalational or transdermal venous anaesthesia.
• Permission to obtain and review all pertinent medical records, including those concerning anaesthesia, the perioperative phase, and any information gathered during or subsequent to the operation.

Exclusion Criteria

• Individuals undergoing emergent surgical procedures.
• Patients whose anaesthesia information is absent or who have inadequate medical records.
• Individuals with a cognitive impairment that prevents them from giving informed assent.

Data Collection Process and Sources

The databases at Dr. SNMC College, Jodhpur, which comprise anaesthesia records and electronic medical records (EMRs), would be queried for the necessary information. Relevant information will include patient demographics, preoperative medical conditions, anaesthetic type and dosage, intraoperative parameters (including duration of surgery and incidence of intraoperative complications), postoperative outcomes (including assessment of cognitive function, recovery time, and incidence of postoperative delirium), and overall rates of complications.

Sample Size Calculation and Justification

The sample size will be determined based on the primary outcome measure, which is the incidence of postoperative delirium. A priori power analysis will be performed using statistical software, considering an estimated effect size based on existing literature and desired level of statistical power (e.g., 80%). Given the retrospective nature of the study and the available sample population at Dr. SNMC College, Jodhpur, a sample size of 40 patients in each anesthesia group is deemed feasible to detect clinically significant differences between groups.

Statistical Methods Used for Analysis

We will base the sample size on postoperative delirium, the main outcome. To determine study power, statistical approaches will be used. This method considers statistical power (80% in this example) and literature-predicted impact size. Given Dr. SNMC College, Jodhpur's population and retrospective technique, 40 patients per anaesthetic group should be enough to detect statistically significant differences.

Ethical Considerations

The examination will follow all ethical standards, including the Helsinki Declaration. Before data collection begins, the Jodhpur Dr. SNMC College IRB must approve. To protect our patients' privacy, we'll anonymize their data and follow their confidentiality requests. The retrospective study does not require informed permission because patient data is de-identified and anonymized during analysis. The study must be honest and transparent, and any conflicts of interest must be disclosed.

Study Design

In elderly patients undergoing surgical procedures, the intention of this retrospective study is to compare the effectiveness of total intravenous anaesthesia (TIVA) and inhalational anaesthesia. In order to investigate sizable patient cohorts over an extended period of time in an efficient manner, retrospective studies analyse data collected for objectives unrelated to the current inquiry.

Inclusion and Exclusion Criteria

Inclusion Criteria

• Individuals who wish to undergo elective surgical procedures must be at least 65 years old.
• Individuals who will be undergoing surgical procedures under inhalational or transdermal venous anaesthesia.
• Permission to obtain and review all pertinent medical records, including those concerning anaesthesia, the perioperative phase, and any information gathered during or subsequent to the operation.

Exclusion Criteria

• Individuals undergoing emergent surgical procedures.
• Patients whose anaesthesia information is absent or who have inadequate medical records.
• Individuals with a cognitive impairment that prevents them from giving informed assent.

Data Collection Process and Sources

The databases at Dr. SNMC College, Jodhpur, which comprise anaesthesia records and electronic medical records (EMRs), would be queried for the necessary information. Relevant information will include patient demographics, preoperative medical conditions, anaesthetic type and dosage, intraoperative parameters (including duration of surgery and incidence of intraoperative complications), postoperative outcomes (including assessment of cognitive function, recovery time, and incidence of postoperative delirium), and overall rates of complications.

Sample Size Calculation and Justification

The sample size will be determined based on the primary outcome measure, which is the incidence of postoperative delirium. A priori power analysis will be performed using statistical software, considering an estimated effect size based on existing literature and desired level of statistical power (e.g., 80%). Given the retrospective nature of the study and the available sample population at Dr. SNMC College, Jodhpur, a sample size of 40 patients in each anesthesia group is deemed feasible to detect clinically significant differences between groups.

Statistical Methods Used for Analysis

We will base the sample size on postoperative delirium, the main outcome. To determine study power, statistical approaches will be used. This method considers statistical power (80% in this example) and literature-predicted impact size. Given Dr. SNMC College, Jodhpur's population and retrospective technique, 40 patients per anaesthetic group should be enough to detect statistically significant differences.

Ethical Considerations

The examination will follow all ethical standards, including the Helsinki Declaration. Before data collection begins, the Jodhpur Dr. SNMC College IRB must approve. To protect our patients' privacy, we'll anonymize their data and follow their confidentiality requests. The retrospective study does not require informed permission because patient data is de-identified and anonymized during analysis. The study must be honest and transparent, and any conflicts of interest must be disclosed.

Table 1 Demographic Characteristics of the Study Population

The table1 illustrates the study participants' demographics and how the American Society of Anesthesiologists (ASA) classified them by type of anaesthesia (TIVA): inhalational or complete intravenous. Researchers averaged 72.5 years old; TIVA participants were 71.8 years old and inhalational participants were 73.2. TIVA included younger-than-average people. Both groups included equal male and female patients. Most TIVA and inhalational patients were ASA II, indicating mild to moderate systemic illness without functional restrictions. No statistically significant variations in ASA categorization meant the two anaesthesia groups had similar baseline health condition. Based on demographics and ASA categorization, the study population was evenly split between inhalational anaesthesia and TIVA. This method reduced confounding variables' impact on clinical results.

Comparison of Baseline Characteristics between TIVA and Inhalational Anesthesia Groups

Table 2 Comparison of Baseline Characteristics between TIVA and Inhalational Anesthesia group

The table 2 presents a comparison between inhalational anaesthesia and total intravenous anaesthesia (TIVA) based on demographic characteristics and ASA (American Society of Anesthesiologists) classification. Based on the obtained mean ages of 71.8 and 73.2 years, respectively (p=0.312), it can be inferred that the age distributions of the two groups were comparable. The gender distribution of patients in the TIVA and inhalational groups was identical (p=1.000), with an equal number of male and female patients in each group. In accordance with the ASA classification, the majority of patients in both categories were ASA II, which denotes mild to moderate systemic disease devoid of functional limitations. Regarding ASA I (p=0.586), ASA II (p=1.000), and ASA III (p=0.693), the distribution of ASA did not differ significantly between the TIVA and inhalational groups in a statistical sense. Based on the findings, the comparison of clinical outcomes between the TIVA and inhalational anaesthesia groups was unlikely to have been influenced by numerous confounding variables, as age, gender, and ASA classification were all balanced.

Table 3 Primary Outcome of  Incidence of Postoperative Delirium

This table 3 compares surgical delirium rates after TIVA versus inhalational anaesthesia. Five TIVA patients (12.5%) and eight inhalational patients (20.0%) suffered postoperative delirium. The two groups had similar postoperative delirium rates (p=0.348). The results show that TIVA and inhalational anaesthesia did not increase postoperative delirium in the study population. Research with larger samples may be needed to explain postoperative delirium in older surgical patients.

Secondary Outcomes

Recovery Time: The inhalational group had a median recovery time of 35 minutes (IQR: 30-40 minutes) compared to 30 minutes (IQR: 25-35 minutes) for the TIVA group (p=0.041).

Postoperative Cognitive Function: There was no statistically significant difference observed in the cognitive function scores between the TIVA and inhalational anaesthesia groups as measured by the Mini-Mental State Examination (MMSE) (p=0.183).

Overall Complication Rates: Although there was no statistically significant difference, the inhalational group had 22.5% complications compared to the TIVA group's 15.0%.

Demographic data are similar between TIVA and inhalational anaesthesia groups, including age, gender, and ASA classification. Although not statistically significant, inhalational anaesthesia increased postoperative delirium. TIVA improved surgical recovery time more than inhalational anaesthesia, which is significant. Further studies found no significant differences in postoperative cognitive impairment or overall complications between groups. These findings add to the growing body of research on geriatric surgery patients' anaesthetic management and emphasise the importance of anaesthesia type in improving perioperative care for this at-risk group.

This study is helpful because it compares the effects of total intravenous anaesthesia (TIVA) and inhalational anaesthesia on older people who are having surgery. In contrast to what was thought at first, the rates of confusion after surgery were about the same in both groups. The TIVA group had a lower rate of confusion after surgery than the inhalational group, but the difference was not statistically significant. The two groups had different recovery times. The TIVA group recovered faster than the inhalational group. Cognitive function and post-surgery complications were likewise similar between the two anaesthetic groups.

Clinical Implication

These findings have major implications for senior surgical anaesthesia therapy. Although TIVA did not reduce surgical delirium, it may improve early recovery and release preparedness due to its link with shorter recovery lengths. Clinicians may consider these factors when considering older patient anaesthesia treatments to balance perioperative outcomes and patient preferences.

Table 4 Comparison with Previous Research

Several studies on anaesthetic treatments for elderly surgical patients have different designs, sample sizes, and outcomes, as demonstrated by this comparison. Several studies suggest that TIVA is more advantageous than inhalational anaesthesia for a variety of reasons, such as a reduced probability of postoperative delirium and a shortened recovery period. However, it is possible that other studies have failed to detect any differences or have identified certain constraints, such as the utilisation of comparatively limited sample sizes. Additional investigation is required in order to clarify ambiguities and reach more conclusive findings concerning the most effective anaesthetic method for geriatric patients undergoing surgical procedures.

Limitations of the Study

Retroactive studies may introduce selection bias, making causation impossible to prove. The limited sample may not have shown whether TIVA and inhalational groups performed better. Due to its single-center design, study results may not apply to other locations or patient populations. Only using medical records may result in inaccurate results due to mistakes or missing data.

Areas for Future Research

This field offers several study possibilities. Larger prospective trials with various patient demographics and multi-center partnerships would better demonstrate the relative safety and efficacy of TIVA and inhalational anaesthesia in older surgical patients. To fully understand patient outcomes, longitudinal studies should evaluate various anaesthesia procedures over time and document their effects on cognitive function, quality of life, healthcare use, and short- and long-term outcomes. To reduce postoperative delirium in older surgical patients, preoperative treatments or intraoperative surveillance may be tested.

The study finished by comparing Geriatric surgery patients under inhalational and complete intravenous anaesthesia. Even though inhalational and TIVA had similar postoperative delirium rates, TIVA recovered faster. Thus postoperative cognitive performance and complication rates were similar across groups. We found that TIVA and inhalational anaesthesia work for Geriatric surgery patients due to their particular needs. This study shows the value of made-to-order perioperative treatment in enhancing health outcomes for older patients after surgery and advances anaesthesia knowledge. Larger prospective trials with long-term follow-up are needed to support geriatric surgery anaesthetic approaches.

1. Tariq, F. Iqbal, Z. Younus, and W. Chaudhary, "The Impact of Total Intravenous Anesthesia Versus Inhalational Anesthesia on Postoperative Cognitive Dysfunction in Elderly Patients," Biological and Clinical Sciences Research Journal, vol. 2023, no. 1, pp. 580-580, 2023.
2. Song, L. J. Wu, and L. Li, "Comparison of combined intravenous and inhalation anesthesia and total intravenous anesthesia in laparoscopic surgery and the identification of predictive factors influencing the delayed recovery of neurocognitive function," Frontiers in Medicine, vol. 11, p. 1353502, 2024.
3. Y. Huang et al., "Total intravenous anesthesia for geriatric hip fracture with severe systemic disease," European Journal of Trauma and Emergency Surgery, vol. 49, no. 5, pp. 2139-2145, 2023.
4. Negrini et al., "Incidence of postoperative cognitive dysfunction following inhalational vs total Intravenous General Anesthesia: a systematic review and Meta-analysis," Neuropsychiatric Disease and Treatment, vol. 18, pp. 1455, 2022.
5. Beverstock et al., "A comparison of volatile anesthesia and total intravenous anesthesia (TIVA) effects on outcome from cardiac surgery: a systematic review and meta-analysis," Journal of Cardiothoracic and Vascular Anesthesia, vol. 35, no. 4, pp. 1096-1105, 2021.
6. L. Jiang et al., "Volatile versus Total intravenous anesthesia on postoperative delirium in adult patients undergoing cardiac valve surgery: A randomized clinical trial," Anesthesia & Analgesia, vol. 136, no. 1, pp. 60-69, 2023.
7. Huang and Y. Zhang, "The effect of intravenous and inhalation anesthesia in general on the cognition of elderly patients undergoing non-cardiac surgery: a systematic review and meta-analysis," Frontiers in Medicine, vol. 10, p. 1280013, 2023.
8. Shin et al., "Effects of anesthesia techniques on outcomes after hip fracture surgery in elderly patients: a prospective, randomized, controlled trial," Journal of Clinical Medicine, vol. 9, no. 6, pp. 1605, 2020.
9. Jin et al., "Long-term prognosis after cancer surgery with inhalational anesthesia and total intravenous anesthesia: a systematic review and meta-analysis," International journal of physiology, pathophysiology and pharmacology, vol. 11, no. 3, pp. 83, 2019.
10. K. Oh et al., "Comparison of the postoperative liver function between total intravenous anesthesia and inhalation anesthesia in patients with preoperatively elevated liver transaminase levels: a retrospective cohort study," Therapeutics and Clinical Risk Management, pp. 223-232, 2020.