Sickle cell disease (SCD) is a major public health concern in India, with a particularly high genetic burden concentrated in the tribal belts of Koraput, Odisha. One of the most painful and mobility-limiting complications of SCD is avascular necrosis (AVN) of the femoral head, caused by chronic microvascular blockages in the bone marrow. For patients suffering from severe AVN, Total Hip Replacement (THR) is a life-changing surgery. However, bringing a patient with SCD into the operating theater requires meticulous care. The main goal for the anaesthesiologist is to prevent a "sickling crisis." Red blood cells in these patients can rapidly sickle and block blood vessels if exposed to triggers like cold temperatures, low oxygen, dehydration, or surgical stress. General anaesthesia is often avoided due to the risks of airway irritation, hypoventilation, and delayed recovery. Therefore, regional anaesthesia is usually the gold standard. The ongoing debate in our field is whether to use spinal or epidural anaesthesia. Spinal anaesthesia is incredibly reliable and works fast, but it often causes a sudden drop in blood pressure (hypotension), which can reduce blood flow to tissues and trigger sickling. Epidural anaesthesia takes longer to set in, but it allows the body's blood pressure to adjust gradually. Plus, the epidural catheter can be left in place to manage severe postoperative pain—a known trigger for sickle cell crises. This study, conducted at SLN MCH, Koraput, aims to directly compare these two techniques to find the safest approach for our local SCD population undergoing THR.

Study Design and Patients We conducted a prospective, randomized, comparative study at SLN MCH, Koraput, spanning from January 2024 to December 2025. Following approval from our Institutional Ethics Committee, we enrolled 60 patients (aged 18–55) with confirmed Sickle Cell Disease (either HbSS or HbAS) who were scheduled for elective THR. We excluded patients who had severe heart or lung issues, bleeding disorders, infections at the injection site, or those who had suffered an acute vaso-occlusive crisis or chest syndrome within the past month. Anaesthetic Protocol • Patients were randomly divided into two equal groups of 30: • Group S (Spinal): Received a single shot of 12.5 to 15 mg of 0.5% hyperbaric bupivacaine in the lower back (L3-L4 space). • Group E (Epidural): An epidural catheter was placed at the L3-L4 or L4-L5 space. We slowly administered 15–20 mL of 0.5% isobaric bupivacaine in increments. • To prevent sickling, all patients were given warm IV fluids before surgery and were kept warm with forced-air blankets. Supplemental oxygen was provided throughout the procedure. What We Measured We tracked the Mean Arterial Pressure (MAP) and Heart Rate closely. We noted how fast the patients went numb (sensory block) and couldn't move their legs (motor block). After surgery, we monitored their pain levels using a Visual Analog Scale (VAS) for 24 hours. A drop in MAP of more than 20% from their baseline was treated as a complication (hypotension). We used SPSS software for statistical analysis. A p-value of <0.05 was considered statistically significant.

Both groups were similar in terms of age, gender, weight, and baseline haemoglobin levels. This ensures our comparison was fair from the start. Table 1: Patient Demographics and Baseline Clinical Profile Parameter Group S (Spinal) (n=30) Group E (Epidural) (n=30) p-value Age (years) 31.8±5.4 32.5±6.1 0.640 Gender (Male/Female) 19/11 17/13 0.592 Weight (kg) 55.1±7.8 57.0±8.2 0.364 Baseline Hb (g/dL) 8.4±1.2 8.7±1.0 0.297 Baseline MAP (mmHg) 91.5±6.2 92.1±5.9 0.702 Spinal anaesthesia worked significantly faster than epidural anaesthesia, establishing complete numbness and lack of movement in mere minutes. Table 2: Block Characteristics Parameter Group S (Spinal) Group E (Epidural) p-value Onset of Sensory Block (min) 3.8±1.1 15.5±3.4 <〖0.001〗^* Time to Max Motor Block (min) 5.5±1.4 20.1±4.5 <〖0.001〗^* Duration of Analgesia Fixed (single shot) Titratable via catheter N/A *Statistically significant. However, this rapid onset in the spinal group came at a cost to blood pressure. Group S experienced a sharp, sudden drop in MAP shortly after the injection. Group E's blood pressure remained remarkably stable. Table 3: Intraoperative Hemodynamic Changes (MAP in mmHg) Time Interval Group S (MAP) Group E (MAP) p-value Baseline 91.5±6.2 92.1±5.9 0.702 5 mins post-block 76.4±8.5 89.2±6.1 <〖0.001〗^* 15 mins post-block 71.8±7.9 85.6±5.5 <〖0.001〗^* 30 mins post-block 80.2±6.4 86.8±5.0 〖0.001〗^* 60 mins post-block 85.1±5.8 88.0±4.5 〖0.035〗^* Postoperative pain management is crucial for SCD patients. Thanks to the epidural catheter, Group E experienced vastly superior pain control throughout the first critical 24 hours. Table 4: Postoperative Pain Management (VAS Scores) Time Post-Op Group S (VAS Score) Group E (VAS Score) p-value 2 Hours 1.4±0.7 1.1±0.5 0.058 6 Hours 4.8±1.1 1.7±0.6 <〖0.001〗^* 12 Hours 4.1±1.3 1.5±0.7 <〖0.001〗^* 24 Hours 3.2±1.0 1.4±0.5 <〖0.001〗^* When looking at complications, hypotension was the most glaring issue in the spinal group, requiring medical intervention (IV fluids and ephedrine). We noted a few mild vaso-occlusive crises postoperatively, but no life-threatening acute chest syndrome occurred in either group. Table 5: Perioperative Complications Complication Group S (n=30) Group E (n=30) p-value Hypotension (>20% drop) 11 (36.6%) 3 (10.0%) 〖0.015〗^* Bradycardia (HR < 50 bpm) 5 (16.6%) 1 (3.3%) 0.085 Shivering 7 (23.3%) 2 (6.7%) 0.070 Mild Vaso-Occlusive Crisis 3 (10.0%) 1 (3.3%) 0.301

Taking care of a patient with Sickle Cell Disease in the operating room is a delicate balancing act. You need deep enough anaesthesia to perform a major bone surgery like a Total Hip Replacement, but you cannot afford to disrupt the body’s physiological harmony. If a patient gets too cold, lacks oxygen, or suffers a sudden drop in blood pressure, their red blood cells can sickle, leading to excruciating pain and organ damage. Our results at SLN MCH, Koraput, clearly highlight the physiological trade-offs between spinal and epidural anaesthesia. Spinal anaesthesia is undeniably faster. But the very mechanism that makes it fast—a rapid blockade of the sympathetic nervous system—causes blood vessels to dilate suddenly. This led to a significant drop in mean arterial pressure in over a third of our spinal group patients. In a patient with SCD, this sudden sluggish blood flow (venous stasis) is a prime setup for a sickling crisis. Epidural anaesthesia, on the other hand, acts like a dial rather than an on/off switch. By injecting the anesthetic slowly, the blood vessels dilate gradually. The patient's body has time to compensate, and we have time to administer IV fluids to keep the blood pressure beautifully stable. Equally important is what happens after the surgery is over. Severe pain triggers a stress response in the body, constricting blood vessels and increasing the heart's oxygen demand—both dangerous for an SCD patient. Because we could leave the epidural catheter in place, Group E received continuous, tailored pain relief. Their VAS scores remained exceptionally low for the first 24 hours compared to the spinal group, who relied on IV painkillers once their single-shot block wore off.

For patients with Sickle Cell Disease undergoing Total Hip Replacement, both techniques can be utilized safely with rigorous perioperative care. However, epidural anaesthesia stands out as the clinically superior choice. It protects the patient from sudden, dangerous drops in blood pressure during surgery and provides a seamless bridge to exceptional postoperative pain control. In high-prevalence areas like Koraput, making epidural anaesthesia the standard of care for these major orthopedic procedures can tangibly reduce perioperative stress and improve patient outcomes

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