Variability of duration of action of neuromuscular‐blocking drugs in elderly patients

Arain, Shahbaz R.; Kern, Steven E.; Ficke, David J.; Ebert, Thomas J.

doi:10.1111/j.1399-6576.2005.00634.x

Cited by 83 publications

(65 citation statements)

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“…Throughout onset of non-depolarizing block, T 4 disappears at about 75% depression of T 1 , T 3 at 80-85% depression of T 1 , and T 2 at 90% depression. During recovery from non-depolarizing block: T 1 appears again, first followed by T 2 , T 3 , and finally T 4 (4). .…”

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confidence: 97%

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A Comparision of the Effect of Sugammadex on the Recovery Period and Postoperative Residual Block in Young Elderly and Middle-Aged Elderly Patients

Yazar¹,

Yılmaz²,

Bilgin³

et al. 2016

Balkan Med J

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Background:The importance of the characteristics of anesthesia and postoperative residual curarization (PORC) in the elderly population should be a growing concern in this century. Aims: To investigate the effect of sugammadex on the duration of the recovery from neuromuscular blocking agents and postoperative residual curarization in the young elderly and middle-aged elderly patients who underwent elective laparoscopic cholecystectomy, followed by a train of four (TOF) watch monitorization. Study Design: Prospective clinical trial study. Methods: Sixty patients over the age of 65 with American Society of Anesthesiologists I-III were divided into two groups according to their age (65-74 years old and ≥75 years old). Patients received sugammadex (2.0 mg/ kg iv) at the reappearance of the second twitch of the TOF as an agent for reversal of neuromuscular blockage at the end of surgery. Patients were extubated at the time of TOF ≥0.9. The patients' TOF responses were evaluated with regards to PORC in at the 5th minute and were followed up for one hour in the recovery room. Reintubation was applied for those patients who developed PORC and had peripheric oxygen saturation <90% despite being given 6 L oxygen per min with a face mask. Results: The onset time of neuromuscular blocking agent and time from T 2 to achieve TOF ratio 90% (the duration of sugammadex effect) or over were found to be longer in the middle-aged elderly group than in the young elderly group. A statistically significant relationship was found between age and the duration of TOF ratio to reach 0.9 in the same direction. The PORC incidence and rate of reintubation were found to be 1.7% in all patients. Conclusion: In our opinion, it is necessary to remember that the duration of sugammadex effect on the recovery period is prolonged for patients who are aged ≥75 years compared to patients aged between 65-74 years. (ClinicalTrials.gov Identifier: ACTRN12615000758505) Keywords: Elderly, postoperative residual curarization, reintubation, sugammadex Young elderly people, middle-aged elderly people, and old elderly people have been classified, respectively, between 65-74 years of age, between 75-84 years of age, and over age 84 by gerontologists (1). A number of studies have indicated that the prevalance of postoperative residual curarization (PORC) increases with age (2,3).The principle of train of four (TOF) Watch was to indicate a pattern of stimulation that did not require the comparison of evoked responses to a control response obtained before administration of a neuromuscular blocking agent (NMBA). As well as enabling the observer to compare T 1 (first twitch of the TOF) to T 0 (control), it also enables comparison of T 4 (fourth

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mentioning

confidence: 97%

“…A number of studies have indicated that the prevalance of postoperative residual curarization (PORC) increases with age (2,3).…”

mentioning

confidence: 99%

A Comparision of the Effect of Sugammadex on the Recovery Period and Postoperative Residual Block in Young Elderly and Middle-Aged Elderly Patients

Yazar¹,

Yılmaz²,

Bilgin³

et al. 2016

Balkan Med J

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“…On the basis of previous publications, we defined a priori the following variables that might influence the variance in duration of action of cisatracurium and rocuronium: weight, 15,16 age, 17 sex, 18 ASA score, 19 blood loss, 20,21 lowest core body temperature, 22 duration of NBD administration, 23 and history of tobacco smoking. [24][25][26] Variables that correlated significantly (P = .15) with the mean dur 25 were included in our multiple regression analysis model, and an association of variables with the dur 25 of the respective NBD was assumed at a significance level of less than .05.…”

Section: Discussionmentioning

confidence: 99%

“…Both of these NBDs are often used in anesthesia and intensive care medicine. 4 On the basis of published data, we thought that weight, 15,16 age, 17 sex, 18 American Society of Anesthesiologists (ASA) risk score, 19 blood loss (suggesting instability of cardiac output), 20,21 lowest core body temperature, 22 duration of NBD administration, 23 and tobacco smoking history [24][25][26] might contribute to the variance in the mean duration of action of cisatracurium and rocuronium.…”

mentioning

confidence: 99%

Clinical Predictors of Duration of Action of Cisatracurium and Rocuronium Administered Long-Term

Faßbender

Geldner

Blobner

et al. 2009

American Journal of Critical Care

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BackgroundThe duration of action of neuromuscular blocking drugs (NBDs) varies between individuals and even within individuals in different settings. Objectives To define predictors of variance in duration of action of rocuronium and cisatracurium administered long-term. Methods A prospective, double-blind, multicenter trial that included 113 patients scheduled for major abdominal surgery and postoperative admission to the intensive care unit. Patients received repetitive (median, 7) equipotent doses of rocuronium or cisatracurium to maintain deep relaxation (twitch height of the adductor pollicis muscle <25% of baseline). Effects of weight, age, sex, American Society of Anesthesiologists risk score, lowest core temperature, duration of NBD administration, and tobacco smoking history on duration of action of cisatracurium and rocuronium were determined via multiple regression analysis. Results Only duration of NBD administration was predictive of the duration of action of rocuronium. The predicted increase in time to recovery of the train-of-4 ratio to 0.9 (duration TOF 0.9) per hour of continuous NBD treatment was 12.4 minutes. In contrast, only lowest core body temperature was predictive of cisatracurium's duration of action, and the predicted in crease in duration TOF 0.9 per degree Celsius decrease was 9.8 min. Conclusion Duration of NBD treatment is strongly predictive of the duration of action of rocuronium, and body temperature is predictive of the duration of action of cisatracurium. These data may help decrease the incidence of drug-induced muscle weakness in recovery rooms and surgical intensive care units, particularly if neuromuscular transmission monitoring is not available.

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“…In this respect, benzylisoquinoline derivatives have an advantage over aminosteroids. Indeed, Arain et al [33] defined variability in the duration of neuromuscular block as the difference between its duration in a respective patient and the mean duration in the entire patient group. The duration of a neuromuscular blockade following the administration of vecuronium and rocuronium in patients over 60 years of age demonstrated a greater variability compared to cisatracurium.…”

Section: Benzylisoquinoline Derivativesmentioning

confidence: 99%

Blokada nerwowo-mięśniowa u osób w podeszłym wieku

Stankiewicz-Rudnicki

2016

Anaesthesiol Intensive Ther

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The aim of the presented review is to highlight the clinical problem of postoperative residual curarization (PORC) following general anaesthesia in the elderly. Possible complications of PORC are described along with age-induced changes in pharmacokinetics of long and intermediate-acting neuromuscular blocking agents. This is intended to facilitate the selection and to promote appropriate intraoperative use of muscle relaxants in patients over the age of 65 years.Key words: elderly patients; neuromuscular block, muscle relaxants; neuromuscular block, reversal; postoperative residual curarization Anaesthesiology Intensive Therapy 2016, vol. 48, no 4, 257-260 Anaesthesiologists are regularly involved in the treatment of elderly patients due to the increasing life expectancy and rising number of surgeries in the aging population [1]. General anaesthesia comprises four crucial components: unconsciousness, analgesia, immobilization and haemodynamic stability [2]. Neuromuscular block serves the two latter purposes. As it maintains good surgical conditions as well as facilitating airway management, doses of both volatile and intravenous anaesthetics can be considerably reduced. This is of importance in patients over 65 years of age, particularly those older than 75. This group of patients is most susceptible to the adverse effects of anaesthetics [3], including decreased heart muscle contractility and hypotension, which pose a risk of cardiac and central nervous system ischaemia [4].Unfortunately, advanced age is accompanied by an increasing risk of postoperative residual curarization (PORC) [5] which, along with intraoperative awareness [6], is one of the most clinically significant complications of the use of muscle relaxants. Residual blockade is currently defined by the train of four ratio (TOFR) < 0.9, although previous reports mentioned TOFR < 0.7. It may lead to severe respiratory complications in the post-operative period [7], and thus prolong hospitalization. Awareness of the specific issues of neuromuscular blocking agents use in the elderly is therefore crucial in daily anaesthesiological practice. CliniCal aspeCts of the pharmaCokinetiCs of neuromusCular bloCking agents in the elderlyDoses of both steroid and benzylisoquinoline-derived non-depolarising muscle relaxants necessary to reach maximal block, i.e. 95% reduction of muscle response to a stimulus (effective dose 95 , ED 95 ), do not vary significantly between elderly persons and younger subjects [8,9]. This suggests that the physiology of the neuromuscular junction and the pharmacodynamics of neuromuscular blocking agents are not markedly altered in advanced age. It is the pharmacokinetics of these agents that is responsible for their altered clinical effects in the elderly.Decreased cardiac output is accompanied by reduced skeletal muscle perfusion [3] and, consequently, one should expect a prolonged time to maximum blockade following drug administration [10,11]. However, doses of muscle relaxants used for intubation are two to three, or ...

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Variability of duration of action of neuromuscular‐blocking drugs in elderly patients

Abstract: When used with sevoflurane/N(2)O, there was a two-fold greater variability of duration of neuromuscular blockade in elderly patients receiving rocuronium or vecuronium compared with cisatracurium.

Cited by 83 publications

References 19 publications

A Comparision of the Effect of Sugammadex on the Recovery Period and Postoperative Residual Block in Young Elderly and Middle-Aged Elderly Patients

A Comparision of the Effect of Sugammadex on the Recovery Period and Postoperative Residual Block in Young Elderly and Middle-Aged Elderly Patients

Clinical Predictors of Duration of Action of Cisatracurium and Rocuronium Administered Long-Term

Blokada nerwowo-mięśniowa u osób w podeszłym wieku

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