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Residual Neuromuscular Blockade and Perioperative Outcomes in the Elderly

Abstract

Purpose of Review

The aim of this review is to assess clinical investigations which have examined the use of NMBAs in the elderly, and to recommend neuromuscular management strategies that may optimize recovery in this patient population.

Recent Findings

A number of clinical studies have assessed the effect of age on NMBA duration. Recovery from cisatracurium has been compared to steroid-based NMBAs (rocuronium and vecuronium) in the elderly. Variability in the duration of action was significantly greater with the steroid-based drugs than cisatracurium. Other studies have demonstrated that the elderly not only demonstrate prolonged recovery from rocuronium and vecuronium neuromuscular blockade, but also significantly more variability in the times to achieve full neuromuscular recovery. Furthermore, reversal of neuromuscular blockade with anticholinesterase agents may require significantly more time in patients older than 70 years of age. Recent clinical trials have demonstrated the elderly are at significantly increased risk for postoperative residual block. Furthermore, older patients not achieving a train-of-four ratio of greater than 0.9 at the time of tracheal extubation are at an increased risk of hypoxemic events, airway obstruction, and unpleasant signs and symptoms of muscle weakness. Reversal of neuromuscular blockade with sugammadex results in a low incidence of residual block; however, the times to achieve a train-of-four ratio of 0.9 are increased in patients over the age of 70.

Summary

The pharmacodynamics and pharmacokinetic effects of neuromuscular blocking agents are altered in the elderly. When steroid-based muscle relaxants are administered, the time required to achieve full neuromuscular recovery is increased, and significantly more variability in recovery times is observed. Patients over the age of 65 years are at an increased risk of postoperative residual neuromuscular blockade and complications related to incomplete neuromuscular recovery. Increased vigilance in managing dosing, monitoring, and reversal is required in the elderly in order to improve perioperative outcomes.

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References

Papers of particular interest, published recently, have been highlighted as: •Of importance

  1. 1.

    Cope TM, Hunter JM. Selecting neuromuscular-blocking drugs for elderly patients. Drugs Aging. 2003;20:125–40.

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Lien CA, Matteo RS, Ornstein E, Schwartz AE, Diaz J. Distribution, elimination, and action of vecuronium in the elderly. Anesth Analg. 1991;73:39–42.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Vuyk J. Pharmacodynamics in the elderly. Best Pract Res Clin Anaesthesiol. 2003;17:207–18.

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Matteo RS, Backus WW, McDaniel DD, Brotherton WP, Abraham R, Diaz J. Pharmacokinetics and pharmacodynamics of d-tubocurarine and metocurine in the elderly. Anesth Analg. 1985;64:23–9.

    CAS  PubMed  Google Scholar 

  5. 5.

    Parker CJ, Hunter JM, Snowdon SL. Effect of age, gender and anaesthetic technique on the pharmacodynamics of atracurium. Br J Anaesth. 1993;70:38–41.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Heier T, Caldwell JE. Impact of hypothermia on the response to neuromuscular blocking drugs. J Am. 2006;104:1070–80.

    Google Scholar 

  7. 7.

    Arain SR, Kern S, Ficke DJ, Ebert TJ. Variability of duration of action of neuromuscular-blocking drugs in elderly patients. Acta Anaesthesiol Scand. 2005;49:312–5.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Pühringer FK, Heier T, Dodgson M, Erkola O, Goonetilleke P, Hofmockel R, et al. Double-blind comparison of the variability in spontaneous recovery of cisatracurium- and vecuronium-induced neuromuscular block in adult and elderly patients. Acta Anaesthesiol Scand. 2002;46:364–71.

    Article  PubMed  Google Scholar 

  9. 9.

    Xiaobo F, Jianjuan K, Yanlin W. Comparison of the variability of the onset and recovery from neuromuscular blockade with cisatracurium versus rocuronium in elderly patients under total intravenous anesthesia. Braz J Med Biol Res. 2012;45:676–80.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Varrique RM, Lauretti GR, Matsumoto JA, Lanchote VL, de Moraes NV. Pharmacokinetics and pharmacodynamics of rocuronium in young adult and elderly patients undergoing elective surgery. J Pharm Pharmacol. 2016;68:1351–8.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    McCarthy GJ, Cooper R, Stanley JC, Mirakhur RK. Dose-response relationships for neostigmine antagonism of vecuronium-induced neuromuscular block in adults and the elderly. Br J Anaesth. 1992;69:281–3.

    CAS  Article  PubMed  Google Scholar 

  12. 12.

    Naguib M, Kopman AF, Lien CA, Hunter JM, Lopez A, Brull SJ. A survey of current management of neuromuscular block in the United States and Europe. Anesth Analg. 2010;111:110–9.

    Article  PubMed  Google Scholar 

  13. 13.

    Viby-Mogensen J, Jørgensen BC, Ording H. Residual curarization in the recovery room. Anesthesiology. 1979;50:539–41.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Naguib M, Kopman AF, Ensor JE. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis. Br J Anaesth. 2007;98:302–16.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    • Fortier LP, McKeen D, Turner K, de Médicis É, Warriner B, Jones PM, et al. The RECITE study: a Canadian prospective, multicenter study of the incidence and severity of residual neuromuscular blockade. Anesth Analg. 2015;121:366–72. This is the most recent large-scale study from eight Canadian hospitals demonstrating that a high incidence of residual neuromuscular blockade is present at the time of tracheal extubation and at PACU admission.

    Article  PubMed  Google Scholar 

  16. 16.

    Kim KS, Lew SH, Cho HY, Cheong MA. Residual paralysis induced by either vecuronium or rocuronium after reversal with pyridostigmine. Anesth Analg. 2002;95:1656–60.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Baillard C, Gehan G, Reboul-Marty J, Larmignat P, Samama CM, Cupa M. Residual curarization in the recovery room after vecuronium. Br J Anaesth. 2000;84:394–5.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    • Pietraszewski P, Gaszyński T. Residual neuromuscular block in elderly patients after surgical procedures under general anaesthesia with rocuronium. Anaesthesiol Intensive Ther. 2013;45:77–81. Only a few clinical investigations have examined the risk of residual neuromuscular blockade in the elderly. In this observations study, 44% of older patients had residual block, compared to 20% of younger patients. The elderly also had a higher risk of hypoxemic events in the PACU.

    Article  PubMed  Google Scholar 

  19. 19.

    Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear TD, Vender JS, et al. Residual neuromuscular block in the elderly: incidence and clinical implications. Anesthesiology. 2015;123:1322–36.

    Article  PubMed  Google Scholar 

  20. 20.

    Brull SJ, Naguib M, Miller RD. Residual neuromuscular block: rediscovering the obvious. Anesth Analg. 2008;107:11–4.

    Article  PubMed  Google Scholar 

  21. 21.

    • Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg. 2010;111:120–8. Patients over the age of 70 years exhibited a higher risk of residual neuromuscular block compared to a younger cohort (58 vs 30%). In addition, elderly subjects with residual block had a higher incidence of hypoxemic events, airway obstruction, and unpleasant symptoms of muscle weakness when compared to elderly subjects with TOF ratios > 0.9.

    Article  PubMed  Google Scholar 

  22. 22.

    Berg H, Roed J, Viby-Mogensen J, Mortensen CR, Engbaek J, Skovgaard LT, et al. Residual neuromuscular block is a risk factor for postoperative pulmonary complications: a prospective, randomized, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997;41:1095–103.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Bulka CM, Terekhov MA, Martin BJ, Dmochowski RR, Hayes RM, Ehrenfeld JM. Nondepolarizing neuromuscular blocking agents, reversal, and risk of postoperative pneumonia. Anesthesiology. 2016;125:647–55.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Bronsert MR, Henderson WG, Monk TG, Richman JS, Nguyen JD, Sum-Ping JT, et al. Intermediate-acting nondepolarizing neuromuscular blocking agents and risk of postoperative 30-day morbidity and mortality, and long-term survival. Anesth Analg. 2017;124:1476–83.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Kim KS, Cheong MA, Lee HJ, Lee JM. Tactile assessment for the reversibility of rocuronium-induced neuromuscular blockade during propofol or sevoflurane anesthesia. Anesth Analg. 2004;99:1080–5.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Kirkegaard H, Heier T, Caldwell JE. Efficacy of tactile-guided reversal from cisatracurium-induced neuromuscular block. Anesthesiology. 2002;96:45–50.

    Article  PubMed  Google Scholar 

  27. 27.

    Abad-Gurumeta A, Ripollés-Melchor J, Casans-Francés R, Espinosa A, Martínez-Hurtado E, Fernández-Pérez C, et al. A systematic review of sugammadex versus neostigmine for reversal of neuromuscular blockade. Anaesthesia. 2015;70:1441–52.

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    McDonagh DL, Benedict PE, Kovac AL, Drover DR, Brister NW, Morte JB, et al. Efficacy, safety, and pharmacokinetics of sugammadex for the reversal of rocuronium-induced neuromuscular blockade in elderly patients. Anesthesiology. 2011;114:318–29.

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    • Shin S, Han DW, Lee HS, Song MK, Jun EK, Kim SY. Elderly patients require higher doses of sugammadex for rapid recovery from deep neuromuscular block. Basic Clin Pharmacol Toxicol. 2016;118:462–7. This clinical investigation demonstrated that sugammadex was effective in reversing deep neuromuscular blockade in the elderly. However, larger doses were required to achieve a TOF ratio of 0.9 within 2 min.

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Yazar E, Yılmaz C, Bilgin H, Karasu D, Bayraktar S, Apaydın Y, et al. A comparison of the effect of sugammadex on the recovery period and postoperative residual block in young elderly and middle-aged elderly patents. Balkan Med J. 2016;33:181–7.

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Kotake Y, Ochiai R, Suzuki T, Ogawa S, Takagi S, Ozaki M, et al. Reversal with sugammadex in the absence of monitoring did not preclude residual neuromuscular block. Anesth Analg. 2013;117:345–51.

    Article  PubMed  Google Scholar 

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Correspondence to Glenn S. Murphy.

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Conflict of Interest

Torin Shear declares that he has no conflict of interest.

Jeffrey Katz declares that he has no conflict of interest.

Glenn S. Murphy has served as a consultant and speaker for Merck.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Geriatric Anesthesia

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Murphy, G.S., Shear, T. & Katz, J. Residual Neuromuscular Blockade and Perioperative Outcomes in the Elderly. Curr Anesthesiol Rep 7, 350–356 (2017). https://doi.org/10.1007/s40140-017-0242-5

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Keywords

  • Residual neuromuscular blockade
  • Elderly
  • Neuromuscular blocking agents
  • Postoperative outcomes