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

Abstract

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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“…This result was attributed to decreased circulatory system dynamics, and the resulting delay in drug distribution present in elderly people. Similar conclusions were reached by Suzuki et al [8] who compared the return period for muscle strength after using sugammadex in patients between 20 and 50 years of age, as well as those older than 70, and Turkish authors who assessed the effect of age on muscle strength return after using sugammadex in patients between 65 and 74, as well as those older than 75 years of age [9]. In all of the cited articles, age did not affect the presence of side effects, while the medication was considered to be well-tolerated.…”

Forty years of neuromuscular monitoring and postoperative residual curarisation: a meta-analysis and evaluation of confidence in network meta-analysis

“…41,47e49,51,53,56e58,63 Some studies did not specify the measurement time point at the PACU at all. 55 Globally considered, 84 of the 109 included study arms (77%) reported PORC based on TOFRs measured at the PACU. 9e13,17e26, 28,30e33,33,38,39,41,43e46,49,51e53,55e58,61,63 Additional intra-study heterogeneity is introduced by the fact that measurements after PACU arrival were not consistently standardised.…”

Profile of sugammadex for reversal of neuromuscular blockade in the elderly: current perspectives

“…More recently, in a prospective clinical trial, Yazar et al investigated the effect of sugammadex 2 mg/kg on duration of recovery from moderate rocuronium-induced NMB in elderly patients undergoing sevoflurane anesthesia. 44 They found that the median (range) time from T 2 to TOF ratio of 0.9 with sugammadex was 3.27 (1.41–5.37) minutes in younger elderly adults (aged 65–74 years) and 5.5 (2.47–9.54) minutes in older elderly patients (aged ≥75 years) ( P <0.001). 44 …”

“… 44 They found that the median (range) time from T 2 to TOF ratio of 0.9 with sugammadex was 3.27 (1.41–5.37) minutes in younger elderly adults (aged 65–74 years) and 5.5 (2.47–9.54) minutes in older elderly patients (aged ≥75 years) ( P <0.001). 44 …”

“…The findings of all these studies reflect the role of age-related physiologic changes, particularly at muscles and NM junctions (eg, decreased muscle blood flow), as well as age-related effects on the pharmacokinetics and pharmacodynamics of NMBAs, in slowing the reversal of rocuronium-induced NMB by sugammadex in elderly patients. 44 – 46 , 48 , 49 To better comprehend the magnitude of the delay in reversal of rocuronium-induced NMB by sugammadex in elderly compared with younger subjects, we performed a meta-analysis of English-language controlled trials investigating this aspect ( Table 3 ). The meta-analysis of selected studies found a significant ( P =0.0036) mean difference (95% CI) of 1.37 (0.45–2.3) minutes between elderly and younger subjects in reversal time of rocuronium-induced NMB by sugammadex, a delay in the elderly that should be considered in clinical practice ( Figure 1 ).…”