Association of target-controlled versus manually controlled infusion with postoperative recovery outcomes in elderly cardiac surgery patients: an international multi-cohort study

BACKGROUND: Target-controlled infusion (TCI) optimizes drug delivery and hemodynamic stability using individualized pharmacokinetic models. We compared the effects of TCI versus manually controlled infusion (MCI) of propofol and remifentanil on postoperative recovery in elderly cardiac surgery patients. METHODS: An international retrospective cohort study was conducted using data from Union Hospital and the INSPIRE dataset. Elderly patients (≥65 years) receiving TCI were matched 1:1 with those receiving MCI using propensity scores to adjust for confounding variables. The primary outcome was the length of stay in the ICU. Secondary outcomes included postoperative complications and intraoperative hemodynamic stability. RESULTS: Of 1398 enrolled patients, propensity score matching yielded 468 in the Union cohort and 270 in the INSPIRE cohort. In the Union cohort, TCI was associated with a significantly shorter ICU stay (Mean Difference [MD] -0.92 days; 95% CI: -1.68 to -0.17; P = 0.017), lower odds of reintubation (OR 0.94; 95% CI: 0.90-0.99), reduced AKI incidence (OR 0.84; 95% CI: 0.78-0.91), and lower in-hospital mortality (OR 0.95; 95% CI: 0.92-0.99) compared with MCI. Validation in the INSPIRE cohort confirmed shorter ICU stays (MD -1.20 days; 95% CI: -2.32 to -0.80; P = 0.036) and lower reintubation rates (OR 0.96; 95% CI: 0.92-0.99). In both cohorts, TCI was associated with superior intraoperative hemodynamic stability, characterized by lower blood pressure variability and a reduced burden of hypotension. CONCLUSION: TCI is associated with superior intraoperative hemodynamic stability, significantly shorter ICU length of stay, and improved postoperative recovery profiles compared with MCI in elderly cardiac surgery patients.