Onset of motor block was significantly faster for ropivacaine than levobupivacaine (P = 0.02), but the time to be ready for surgery was similar with both drugs. Duration of sensory block was prolonged with levobupivacaine (P = 0.01).

The study gave scientific support and actual figures to many intuitive beliefs: morbidity and mortality are high and are associated with many preoperative comorbidities. All this, combined with an already reduced life expectancy, and a presumably low physiological reserve makes these patients particularly vulnerable to emergency surgery.

As drug abuse among anaesthesiologists has continued, new studies have been conducted to know the theories about susceptibility. Written substance abuse policies and controls must be taken in place and in all countries.

almost 3-fold longer than in younger patients. Nonetheless, even in older patients, reversal with sugammadex does not have to be delayed until the second twitch of the TOF response appears or spontaneous respiration is detected, as is the case with neostigmine.There are likely explanations for the longer recovery time in geriatric patients. The onset of action of injected sugammadex is likely dependent on cardiac output and muscle blood flow. Particularly in women, cardiac output decreases moderately with an age-related decline in heart rate. In addition, limb blood flow decreases progressively with advancing age, probably owing to age-related reduced vascular conductance, loss of muscle mass, and decline in oxygen consumption. Age-associated arteriosclerosis also contributes to further reduction in peripheral perfusion. All of these factors would result in a slower increase in the plasma concentration of sugammadex and a slower decline in the plasma concentration of free rocuronium. Thus, free rocuronium molecules cannot diffuse as swiftly from the neuromuscular junction into the plasma.The authors acknowledge that they did not fix the endtidal concentration of sevoflurane to an age-adjusted minimum alveolar concentration value. Rather, they administered a concentration of 1% to 1.5% according to clinical indications. Thus, the elderly patients may have received a larger minimum alveolar concentration dose of sevoflurane than their younger counterparts. Because sevoflurane substantially enhances the effect of neuromuscular blocking agents, it is possible that the efficacy of sugammadex may be diminished during sevoflurane anesthesia, and this possibility warrants further exploration. Clearly, additional studies are needed to determine the effective dose of sugammadex for more rapid reversal of profound neuromuscular block in older patients. Comment by Kathryn E. McGoldrick, MD Disclosure: The author declares no conflict of interest.