Reversibility of Rocuronium-Induced Profound Neuromuscular Block With Sugammadex in Younger and Older Patients

Abstract

A lthough chronological age is a well-established risk factor for developing cardiovascular diseases, the changes that accumulate with age are highly variable. It has been increasingly recognized that indices of vascular age are more reliable than age per se in prediction of adverse cardiovascular outcomes. Variations in the way these age-related changes occur are a function of many genetic and environmental factors. Some of the pathophysiological mechanisms that characterize the vascular aging phenotype are reviewed, and an overview of the key outcome studies that deal with the value of these vascular health indicators is provided, as well as a discussion of the potential effects on perioperative cardiovascular outcomes. COMMENTDespite an expanding number of effective preventive measures and treatments for such cardiovascular risk factors as hypertension and hypercholesterolemia, cardiovascular disease attributable to aging remains the leading cause of mortality in Western countries. This seeming incongruity results from the reality that age itself is associated with morphological changes in all layers of the vascular tree, including central aortic dilation and thickening of the arterial wall even in the absence of atherosclerotic disease. Functional changes occur as well in the vasculature, and the rate at which these morphological and functional alterations develop is characteristic by enormous interindividual variation. The great physician William Osler demonstrated extraordinary insight when, more than a century ago, he proclaimed, BYou are as old as your arteries.[ Increased arterial stiffness is a direct manifestation of early vascular aging and is accompanied by increased central aortic pressure. Current data imply that aortic pulse wave velocity and augmentation index are the best available noninvasive approximations of arterial stiffness in patients older than and younger than 50 years, respectively. Pulse wave velocity is calculated as the distance (femoral-carotid) divided by time, as derived from the electrocardiogram. These values are more sensitive than traditional risk factors at predicting cardiovascular outcomes. Emerging data have linked increased pulse pressure with stroke, renal failure, and mortality after cardiac surgery, thereby offering evidence that measures of vascular stiffness may yield important information in terms of risk stratification. Moreover, data indicate that blood pressureYreducing therapies specifically targeted to lowering central aortic pressure may offer additional therapeutic advantages in routine clinical practice beyond their basic blood pressureYreducing effects. Whether interventions focused on reducing central aortic pressure can ameliorate the risk for indi-viduals undergoing cardiac and noncardiac surgery is yet to be determined. Comment by Kathryn E. McGoldrick, MD Disclosure: The authors declare no conflict of interest.T he reversibility of rocuronium-induced profound neuromuscular block with sugammadex in younger and older patients was compared. Fifteen young...

Effect of magnesium sulphate on sugammadex reversal time for neuromuscular blockade: a randomised controlled study

“…The results of Suzuki and colleagues [29] suggest that appropriate use of sugammadex is associated with the absence of both residual neuromuscular blockade and severe respiratory events in the PACU. However, there have been reports of residual neuromuscular blockade in specific clinical situations.…”

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

“…In elderly patients, in addition to atherosclerotic changes, decrease in cardiac output, HR and muscular blood flow rate leads the onset of the effect of reversal agents, like other drugs, to be delayed (12). As a consequence of the decrease in regional blood flow, the duration of NMBA's and sugammadex effect is elongated (10,11). A slower increase in the plasma concentration of sugammadex gives rise to slower diffusion of rocuronium from neuromuscular junction.…”

“…In the study of Suzuki et al (10), while post tetanic count (PTC) was 1-2, the reversal effect of sugammadex (4 mg/kg) on neuromuscular blocking was investigated on 30 female patients monitored with acceleromyography, and it was found that the duration of the effect of sugammadex was prolonged three fold in older patients (aged ≥70) compared to younger patients (aged 20-50). This was attributed to the delay in the duration of the effect of sugammadex owing to the decrease in cardiac output and muscular blood flow in the elderly.…”

Performing post-tetanic count during rocuronium blockade has limited impact on subsequent twitch height or train-of-four responses

“…The number of visible PTC responses is inversely related to the depth of the blockade, and it can be used as a guide either to predict the time remaining until recovery of visible TOF response [1][2][3][4][5][6] or to determine the dose of sugammadex or other reversal agents required for adequate reversal. 7 The PTC technique relies on inducing a transient improvement of neuromuscular transmission in the monitored muscle, usually the adductor pollicis. It follows that an artificial recovery is produced only in that muscle and that subsequent responses to single or TOF stimulation might be spuriously elevated.…”