The geriatric population represents an increasingly significant proportion of patients undergoing surgical procedures, primarily due to improved life expectancy and advancements in medical and surgical care. Spinal anaesthesia is frequently employed for lower limb surgeries in elderly patients because of its advantages, such as reduced systemic drug exposure, lower risk of airway complications, and superior postoperative analgesia [3,5]. However, this technique is not without risk. Elderly patients are particularly susceptible to spinal anaesthesia-induced hemodynamic alterations, especially hypotension and bradycardia, which can have serious clinical consequences due to reduced physiological reserve and autonomic dysregulation [1,4,5].

Age-related physiological changes—including decreased baroreceptor sensitivity, diminished cardiac compliance, reduced intravascular volume, and attenuated responsiveness to vasopressors—contribute to the heightened risk of hemodynamic instability following neuraxial blockade in older individuals [2,3]. These changes can compromise perfusion to vital organs and lead to increased perioperative morbidity and mortality if not promptly recognized and managed [6]. Studies have shown that hypotension during spinal anaesthesia in the elderly is primarily due to a reduction in stroke volume and systemic vascular resistance [1,6].

Despite growing international literature, data specifically addressing the hemodynamic effects of spinal anaesthesia in geriatric populations within Indian clinical settings remain limited [2]. Moreover, recent evidence suggests that modifications such as fractional dosing and careful segmental anaesthesia levels can improve stability in high-risk elderly patients [2,4,6]. The use of tools like point-of-care transthoracic echocardiography has also been proposed to predict post-spinal hypotension in elderly patients with cardiac dysfunction [7].

This study aims to evaluate the pattern, magnitude, and clinical management of hemodynamic changes during spinal anaesthesia in patients aged 65 years and above undergoing elective lower limb surgery, thereby contributing to safer anaesthetic practices in elderly surgical patients.

The geriatric population represents an increasingly significant proportion of patients undergoing surgical procedures, primarily due to improved life expectancy and advancements in medical and surgical care. Spinal anaesthesia is frequently employed for lower limb surgeries in elderly patients because of its advantages, such as reduced systemic drug exposure, lower risk of airway complications, and superior postoperative analgesia [3,5]. However, this technique is not without risk. Elderly patients are particularly susceptible to spinal anaesthesia-induced hemodynamic alterations, especially hypotension and bradycardia, which can have serious clinical consequences due to reduced physiological reserve and autonomic dysregulation [1,4,5].

Age-related physiological changes—including decreased baroreceptor sensitivity, diminished cardiac compliance, reduced intravascular volume, and attenuated responsiveness to vasopressors—contribute to the heightened risk of hemodynamic instability following neuraxial blockade in older individuals [2,3]. These changes can compromise perfusion to vital organs and lead to increased perioperative morbidity and mortality if not promptly recognized and managed [6]. Studies have shown that hypotension during spinal anaesthesia in the elderly is primarily due to a reduction in stroke volume and systemic vascular resistance [1,6].

Despite growing international literature, data specifically addressing the hemodynamic effects of spinal anaesthesia in geriatric populations within Indian clinical settings remain limited [2]. Moreover, recent evidence suggests that modifications such as fractional dosing and careful segmental anaesthesia levels can improve stability in high-risk elderly patients [2,4,6]. The use of tools like point-of-care transthoracic echocardiography has also been proposed to predict post-spinal hypotension in elderly patients with cardiac dysfunction [7].

This study aims to evaluate the pattern, magnitude, and clinical management of hemodynamic changes during spinal anaesthesia in patients aged 65 years and above undergoing elective lower limb surgery, thereby contributing to safer anaesthetic practices in elderly surgical patients.

A total of 100 geriatric patients aged 65 years and above undergoing lower limb surgeries under spinal anaesthesia were included in this prospective observational study. The mean age of the study population was 72.4 ± 5.8 years. Males constituted 62% of the participants, while females accounted for 38%. The baseline mean systolic blood pressure (SBP) was 138.6 ± 12.4 mmHg, diastolic blood pressure (DBP) was 82.3 ± 8.7 mmHg, and heart rate (HR) was 78.5 ± 7.2 beats per minute (bpm) (Table 1).

Table 1: Baseline Characteristics of Study Participants (n = 100)

Following administration of spinal anaesthesia using 0.5% hyperbaric bupivacaine, hemodynamic changes were observed in a significant proportion of patients. Hypotension, defined as a drop in SBP of ≥20% from baseline, was noted in 48 patients (48%). Bradycardia (HR < 60 bpm) occurred in 18 patients (18%), of whom 6 (6%) required atropine. Additionally, 28 patients (28%) required ephedrine to manage hypotension (Table 2).

Table 2: Hemodynamic Events During Spinal Anaesthesia

Time-dependent variations in hemodynamic parameters were analyzed at predefined intervals post-spinal anaesthesia. A notable decline in SBP, DBP, and HR was observed at 5 and 10 minutes, with gradual stabilization by 30 minutes. The lowest mean SBP (118.2 mmHg) and HR (69.6 bpm) were recorded at 10 minutes post-induction (Table 3).

Table 3: Mean Hemodynamic Parameters at Various Time Intervals

The maximum observed drop in SBP was 26.7 ± 7.9 mmHg, while the maximum HR reduction was 14.1 ± 5.6 bpm. The mean total ephedrine dose administered for the management of hypotension was 9.6 ± 2.5 mg (Table 4).

Table 4: Maximum Hemodynamic Changes and Interventions

Non-cardiovascular complications included nausea/vomiting in 9% of patients and shivering in 12%. No patient required conversion to general anaesthesia, indicating satisfactory maintenance of spinal anaesthesia throughout the procedure (Table 5).

Table 5: Other Observed Complications

This prospective observational study assessed the hemodynamic effects of spinal anaesthesia in 100 geriatric patients undergoing lower limb surgery at GMC Nizamabad. A high incidence of hypotension (48%) and bradycardia (18%) was observed, with most hemodynamic changes occurring within the first 10 minutes post-spinal block. These findings reinforce the importance of vigilant perioperative monitoring and early intervention in elderly surgical patients to mitigate adverse outcomes.

Our findings are in line with prior studies reporting hypotension rates ranging between 40% and 60% among geriatric patients receiving neuraxial anaesthesia [12,13]. These hemodynamic fluctuations are primarily attributed to sympathetic blockade resulting in peripheral vasodilation, compounded by age-associated physiological changes such as reduced baroreceptor sensitivity, impaired autonomic response, and diminished cardiac compliance [14]. Herrera et al. also highlighted that elderly patients are particularly vulnerable to hypotension regardless of the baricity of the local anaesthetic used [8].

The 18% incidence of bradycardia in our study is comparable to the reported 10–20% range in existing literature. This bradycardia is typically due to reduced venous return and unopposed parasympathetic tone following the sympathetic block. Atropine was required in 6% of cases, underscoring the necessity for readiness to manage such events promptly [12,13].

Hemodynamic parameters reached their nadir around 10 minutes post-spinal anaesthesia and gradually stabilized thereafter, consistent with observations from previous studies suggesting the need for heightened vigilance during the first 15 minutes post-induction [11,14]. Ephedrine was used in 28% of patients to manage hypotension, with an average dose of 9.6 ± 2.5 mg. This aligns with recent reports supporting the efficacy of early vasopressor use in elderly patients undergoing lower limb surgery [9].

Emerging techniques such as combined spinal-epidural anaesthesia and unilateral spinal blocks have shown promise in providing stable hemodynamics in high-risk elderly populations, particularly those with significant cardiovascular comorbidities [9,10]. Our findings support these approaches by emphasizing the need for individualized anaesthetic planning based on patient risk factors.

Overall, no conversions to general anaesthesia occurred, and the rate of complications remained low, reinforcing the safety and efficacy of spinal anaesthesia in well-monitored elderly patients. This study adds to the growing Indian and international evidence base advocating for the safe use of spinal anaesthesia in the elderly when supported by proactive hemodynamic surveillance and appropriate pharmacological intervention [8–14].

This prospective observational study highlights that spinal anaesthesia in geriatric patients undergoing lower limb surgery is associated with a significant incidence of hypotension and bradycardia, particularly within the first 10 minutes following administration. While spinal anaesthesia remains a safe and effective technique in the elderly, it requires careful preoperative evaluation, judicious fluid management, and close intraoperative monitoring to promptly identify and manage hemodynamic fluctuations. The use of vasopressors like ephedrine and anticholinergics such as atropine proved effective in stabilizing patients. No major adverse outcomes or conversions to general anaesthesia occurred, indicating that with appropriate precautions, spinal anaesthesia can be safely administered in this vulnerable population.

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