Authors: Bai Y-X et al.
Journal of Clinical Anesthesia, 2026, 10.1016/j.jclinane.2026.112161
This international multi-cohort retrospective study evaluated whether target-controlled infusion (TCI) of propofol and remifentanil improves postoperative recovery compared with manually controlled infusion (MCI) in elderly patients undergoing cardiac surgery. Elderly cardiac surgery patients are particularly vulnerable to hemodynamic instability and postoperative complications, making anesthetic delivery strategies especially important in this population.
Target-controlled infusion systems use pharmacokinetic models to maintain a specified plasma or effect-site drug concentration, potentially providing more stable anesthetic depth and hemodynamics. However, the impact of this technology on clinically meaningful postoperative outcomes has remained uncertain.
The investigators analyzed data from two large cohorts: the Union Hospital cohort and the INSPIRE dataset. Patients aged 65 years or older undergoing cardiac surgery who received TCI-based anesthesia were compared with those receiving manually controlled propofol and remifentanil infusions. Propensity score matching was used to balance baseline characteristics and reduce confounding.
A total of 1,398 patients were included, and after matching, 468 patients in the Union cohort and 270 in the INSPIRE cohort were analyzed. The primary outcome was ICU length of stay, while secondary outcomes included postoperative complications and intraoperative hemodynamic stability.
In the Union cohort, TCI was associated with a significantly shorter ICU stay compared with manual infusion, with an average reduction of approximately 0.9 days. This finding was confirmed in the independent INSPIRE cohort, where ICU stays were reduced by about 1.2 days in patients receiving TCI anesthesia.
TCI was also associated with improved postoperative outcomes. Patients receiving TCI had lower rates of reintubation, reduced incidence of acute kidney injury, and lower in-hospital mortality compared with those receiving manually controlled infusion. Although the absolute differences were modest, the consistency of these findings across cohorts strengthens the association.
A key mechanistic finding was improved intraoperative hemodynamic stability in the TCI group. Patients receiving target-controlled infusion experienced less blood pressure variability and a lower burden of intraoperative hypotension. Since hypotension and hemodynamic instability are known risk factors for organ injury in cardiac surgery, this improved stability may explain the better postoperative outcomes observed.
Overall, the study suggests that TCI-based anesthesia may enhance perioperative management and postoperative recovery in elderly cardiac surgery patients by delivering more precise anesthetic dosing and reducing hemodynamic fluctuations.
What You Should Know
Target-controlled infusion systems use pharmacokinetic models to maintain a desired drug concentration, providing more predictable anesthetic delivery than manual infusion adjustments.
In elderly cardiac surgery patients, maintaining hemodynamic stability is critical because hypotension and blood pressure variability increase the risk of organ injury.
This large multi-cohort study found that TCI anesthesia was associated with shorter ICU stays and fewer postoperative complications.
Improved intraoperative hemodynamic stability appears to be a key mechanism explaining these benefits.
Although the study is retrospective, the consistent findings across two cohorts suggest that TCI may improve outcomes in elderly cardiac surgery patients.
Key Points
International multi-cohort study including 1,398 elderly cardiac surgery patients.
Target-controlled infusion was associated with shorter ICU length of stay compared with manually controlled infusion.
TCI patients had lower rates of reintubation, acute kidney injury, and in-hospital mortality.
TCI provided improved intraoperative hemodynamic stability with less blood pressure variability and hypotension.
The findings suggest that precision drug delivery using TCI may improve postoperative recovery in elderly cardiac surgery patients.
Thank you to the Journal of Clinical Anesthesia for allowing us to summarize this article.