Differences of Recovery from Rocuronium-induced Deep Paralysis in Response to Small Doses of Sugammadex between Elderly and Nonelderly Patients

Abstract

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Complete recovery from rocuronium-induced muscle paralysis with sugammadex is reported to be delayed in elderly patients. The authors tested a hypothesis that recovery from deep neuromuscular block with low-dose sugammadex is slower (primary hypothesis) and incidence of recurarization is higher (secondary hypothesis) in elderly patients than in nonelderly patients. Methods In anesthetized elderly (n = 20; 76.9 ± 5.0 yr of age) and nonelderly patients (n = 20; 53.7 ± 12.8 yr of age) under deep paralysis with rocuronium, change of train-of-four ratio per minute (primary outcome variable) was measured with an acceleromyograph neuromuscular monitor during spontaneous recovery from rocuronium-induced muscle paralysis (0.6 mg/kg) and after infusion of low-dose sugammadex (50 µg · kg-1 · min-1). Recurarization was defined as the negative change of train-of-four ratio. Results Spontaneous train-of-four ratio recovery rate was significantly slower in the elderly group (median [25th percentile, 75th percentile]: 1.89 [1.22, 2.90] %/min) than in the nonelderly group (3.45 [1.96, 4.25] %/min, P = 0.024). Train-of-four ratio change rate in response to low-dose sugammadex was significantly slower in elderly (0.55 [–0.29, 1.54] %/min) than in the nonelderly group (1.68 [0.73, 3.13] %/min, P = 0.024). Incidence of recurarization was significantly higher in the elderly group than in the nonelderly group (35% vs. 5%, P = 0.044). Multiple linear regression analyses indicate that slower spontaneous train-of-four ratio recovery rate and impaired renal function are two major contributing factors that decrease train-of-four ratio change rate in response to low-dose sugammadex. Conclusions Elderly patients are at greater risk for recurarization and residual muscle paralysis when low-dose sugammadex is administered.

Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus

“…Sugammadex is significantly faster than neostigmine in reversing neuromuscular blockade, and is more likely to be associated with higher TOF values and a lower risk of PORC [120]. Reversal of NMB with sugammadex is rapid, although slightly slower than in younger adults [119], especially with low-dose sugammadex [121].…”

Advantages and pitfalls of clinical application of sugammadex

“…Moreover, based on dose-finding studies, under-dosing of sugammadex is associated with RNMB. A recent study revealed that elderly patients are at greater risk for RNMB when low-dose sugammadex is administered [ 103 ]. Hence, sugammadex should be dosed based on the quantitative analysis of neuromuscular monitoring [ 104 ].…”

Pro-Con Debate: Do We Need Quantitative Neuromuscular Monitoring in the Era of Sugammadex?

“…[36][37][38] When reversal agents in inappropriately low doses are given at deeper levels of block, the phenomenon of reoccurrence of NMB reemerged, 39,40 a problem formerly known as "recurarization." 41 However, even after recommended doses of neostigmine and sugammadex in the absence of quantitative monitoring, reoccurrence of NMB was recently observed particularly in elderly 42 and in obese patients. 43,44 Fifth, quantitative NMM must be performed at the wrist to avoid misinterpretation of the depth of NMB.…”

“…30,32 Consequently, a more liberal use of NMB agents and their reversal agents became common practice. 36–38 When reversal agents in inappropriately low doses are given at deeper levels of block, the phenomenon of reoccurrence of NMB reemerged, 39,40 a problem formerly known as “recurarization.” 41 However, even after recommended doses of neostigmine and sugammadex in the absence of quantitative monitoring, reoccurrence of NMB was recently observed particularly in elderly 42 and in obese patients. 43,44…”