Advertisement

Relaxants and Their Reversal Agents

  • Cynthia A. Lien
  • Takahiro Suzuki

Abstract

Whether or not to maintain neuromuscular block in patients, young or elderly, is very much a matter of debate1 and is influenced by the type of anesthesia administered as well as the planned surgical procedure. Once the decision is made to administer a nondepolarizing neuromuscular blocking agent to an elderly patient, special consideration must be given to the potential for altered pharmacologic behavior in this patient population.

Keywords

Neuromuscular Junction Neuromuscular Blockade Geriatric Patient Neuromuscular Block Neuromuscular Blocking Agent 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Gueret G, Rossignol B, Kiss G, et al. Is muscle relaxant necessary for cardiac surgery? Anesth Analg 2004;99:1330–1333.PubMedCrossRefGoogle Scholar
  2. 2.
    Tomlinson BE, Irving D. The numbers of limb motor neurons in the human lumbosacral cord throughout life. J Neurol Sci 1977;34:213–219.PubMedCrossRefGoogle Scholar
  3. 3.
    Kawamura Y, Okazaki H, O’Brien PC, et al. Lumbar motoneurons of man. I. Numbers and diameter histograms of alpha and gamma axons and ventral roots. J Neuropathol Exp Neurol 1977;36:853–860.PubMedGoogle Scholar
  4. 4.
    Young A, Stokes M, Crowe M. Size, and strength of the quadriceps muscles of old and young men. Clin Physiol 1985;5:145–154.PubMedCrossRefGoogle Scholar
  5. 5.
    Lexell J, Taylor CC, Sjöström M. What is the cause of the ageing atrophy? Total number, size and proportion of different fiber types studied in whole vastus lateralis muscle from 15-to 83-year-old men. J Neurol Sci 1988;84:275–294.PubMedCrossRefGoogle Scholar
  6. 6.
    Forbes GB, Reina JC. Adult lean body mass declines with age: some longitudinal observations. Metabolism 1970;19: 653–663.PubMedCrossRefGoogle Scholar
  7. 7.
    Doherty TJ, Brown WF. Age-related changes in the twitch contractile properties of human thenar motor units. J Appl Physiol 1997;82:93–101.PubMedGoogle Scholar
  8. 8.
    Frolkis VV, Martynenko OA, Zamostan VP. Aging of the neuromuscular apparatus. Gerontology 1976;22:244–279.PubMedGoogle Scholar
  9. 9.
    Oda K. Age changes of motor innervation and acetylcholine receptor distribution on human skeletal muscle fibres. J Neurol Sci 1984;66:327–338.PubMedCrossRefGoogle Scholar
  10. 10.
    Martyn JA, White DA, Gronert GA, et al. Up-and-down regulation of skeletal muscle acetylcholine receptors. Effects on neuromuscular blockers. Anesthesiology 1992;76:822–843.PubMedGoogle Scholar
  11. 11.
    Smith DO. Acetylcholine storage, release and leakage at the neuromuscular junction of mature adult and aged rats. J Physiol 1984;347:161–176.PubMedGoogle Scholar
  12. 12.
    Gronert GA. Disuse atrophy with resistance to pancuronium. Anesthesiology 1981;55:547–549.PubMedGoogle Scholar
  13. 13.
    Novak LP. Aging, total body potassium, fat-free mass and cell mass in males and females between ages of 18–85 years. J Gerontol 1972;27:438–443.PubMedGoogle Scholar
  14. 14.
    Ritschel WA. Pharmacokinetic approach to drug dosing in the aged. J Am Geriatr Soc 1976;24:344–354.PubMedGoogle Scholar
  15. 15.
    Matteo RS, Backus WW, McDaniel DD, et al. Pharmacokinetics and pharmacodynamics of d-tubocurarine and metocurine in the elderly. Anesth Analg 1985;64:23–29.PubMedGoogle Scholar
  16. 16.
    Lien CA, Matteo RS, Ornstein E, et al. Distribution, elimination and action of vecuronium in the elderly. Anesth Analg 1991;73:39–42.PubMedCrossRefGoogle Scholar
  17. 17.
    Wood M. Plasma drug binding: implications for anesthesiologists. Anesth Analg 1986;65:786–804.PubMedGoogle Scholar
  18. 18.
    Cameron M, Donati F, Varin F. In vitro plasma protein binding of neuromuscular blocking agents in different subpopulations of patients. Anesth Analg 1995;81:1019–1025.PubMedCrossRefGoogle Scholar
  19. 19.
    Duvaldestin P, Saada J, Berger JL, et al. Pharmacokinetics, pharmacodynamics, and dose-response relationships of pancuronium in control and elderly subjects. Anesthesiology 1982;56:36–40.PubMedCrossRefGoogle Scholar
  20. 20.
    Rupp SM, Castagnoli KP, Fisher DM, et al. Pancuronium and vecuronium pharmacokinetics and pharmacodynamics of vecuronium in younger and elderly adults. Anesthesiology 1987;67:45–49.PubMedCrossRefGoogle Scholar
  21. 21.
    Ornstein E, Matteo RS, Schwartz AE, et al. Pharmacokinetics and pharmacodynamics of pipecuronium (Arduan) in elderly surgical patients. Anesth Analg 1992;74:841–844.PubMedCrossRefGoogle Scholar
  22. 22.
    Dresner DL, Basta SJ, Ali HH, et al. Pharmacokinetics and pharmacodynamics of doxacurium in young and elderly patients during isoflurane anesthesia. Anesth Analg 1990;71: 498–502.PubMedCrossRefGoogle Scholar
  23. 23.
    O’Hara DA, Fragen RJ, Shanks CA. The effects of age on the dose response curve of vecuronium in adults. Anesthesiology 1987;67:45–49.CrossRefGoogle Scholar
  24. 24.
    Bevan DR, Fiset P, Balendran P, et al. Pharmacodynamic behavior of rocuronium in the elderly. Can J Anaesth 1993; 40:127–132.PubMedGoogle Scholar
  25. 25.
    Bell PF, Mirakhur RK, Clarke RSJ. Dose-response studies of atracurium, vecuronium and pancuronium in the elderly. Anaesthesia 1989;44:925–927.PubMedCrossRefGoogle Scholar
  26. 26.
    Koscielniak-Nielsen ZJ, Bevan JC, Popovic V, et al. Onset of maximum neuromuscular block following succinylcholine or vecuronium in four age groups. Anesthesiology 1993; 79:229–234.PubMedCrossRefGoogle Scholar
  27. 27.
    Rodeheffer RJ, Gerstenblith G, Becker LC, et al. Exercise cardiac output is maintained with advancing age in healthy human subjects: cardiac dilatation and increased stroke work compensate for a diminished heart rate. Circulation 1984;69:203–213.PubMedGoogle Scholar
  28. 28.
    Sorooshian SS, Stafford MA, Eastwood NB, et al. Pharmacokinetics and pharmacodynamics of cisatracurium in young and elderly adult patients. Anesthesiology 1996;84: 1083–1091.PubMedCrossRefGoogle Scholar
  29. 29.
    Fisher DM, Rosen JI. A pharmacokinetic explanation for increasing recovery time following larger or repeated doses of nondepolarizing muscle relaxants. Anesthesiology 1986; 65:286–291.PubMedCrossRefGoogle Scholar
  30. 30.
    McLeod K, Hull CJ, Watson MJ. Effects of ageing on the pharmacokinetics of pancuronium. Br J Anaesth 1979;51: 435–438.PubMedCrossRefGoogle Scholar
  31. 31.
    Cook RD, Freeman JA, Lai AA, et al. Pharmacokinetics and pharmacodynamics of doxacurium in normal patients and in those with hepatic or renal failure. Anesth Analg 1991; 72:143–150.Google Scholar
  32. 32.
    Cashman JN, Luke JJ, Jones RM. Neuromuscular block with doxacurium (BW A938U) in patients with normal or absent renal function. Br J Anaesth 1990;64:186–192.PubMedCrossRefGoogle Scholar
  33. 33.
    Koscielniak-Nielsen ZJ, Law-Min JC, Donati F, et al. Doseresponse relations of doxacurium and its reversal with neostigmine in young adults and healthy elderly patients. Anesth Analg 1992;74:845–850.PubMedCrossRefGoogle Scholar
  34. 34.
    Caldwell JE, Canfell PC, Castagnoli KP, et al. The influence of renal failure on the pharmacokinetics and duration of action of pipecuronium bromide in patients anesthetized with halothane and nitrous oxide. Anesthesiology 1989;70: 7–12.PubMedCrossRefGoogle Scholar
  35. 35.
    Bender AD. The effect of increasing age on the distribution of peripheral blood flow in man. J Am Geriatr Soc 1965; 13:192–198.PubMedGoogle Scholar
  36. 36.
    Leithe ME, Hermiller JB, Magorien RD, et al. The effect of age on central and regional hemodynamics. Gerontology 1984;30:240–246.PubMedGoogle Scholar
  37. 37.
    Kato R, Vassanelli P, Frontino G, et al. Variation in the activity of liver microsomal drug-metabolizing enzymes in rats in relation to age. Biochem Pharmacol 1964;13:1037–1051.PubMedCrossRefGoogle Scholar
  38. 38.
    Bencini AF, Scaf AHJ, Sohn YJ, et al. Hepatobiliary disposition of vecuronium bromide in man. Br J Anaesth 1986;58: 988–995.PubMedCrossRefGoogle Scholar
  39. 39.
    d’Hollander AA, Massaux F, Nevelsteen M, et al. Agedependent dose-response relationship of Org NC45 in anaesthetized patients. Br J Anaesth 1982;54:653–656.PubMedCrossRefGoogle Scholar
  40. 40.
    McCarthy G, Elliott P, Mirakhur RK, et al. Onset and duration of action of vecuronium in the elderly: comparison with adults. Acta Anaesth Scand 1992;36:383–386.PubMedCrossRefGoogle Scholar
  41. 41.
    Cooper RA, Maddineni RK, Wierda JMKH, et al. Time course of neuromuscular effects and pharmacokinetics of rocuronium bromide (ORG 9426) during isoflurane anaesthesia in patients with and without renal failure. Br J Anaesth 1993;71:222–226.PubMedCrossRefGoogle Scholar
  42. 42.
    Matteo RS, Ornstein E, Schwartz AE, et al. Pharmacokinetics and pharmacodynamics of rocuronium (Org 9426) in elderly surgical patients. Anesth Analg 1993;77:1193–1197.PubMedCrossRefGoogle Scholar
  43. 43.
    Baykara N, Solak M, Toker K. Predicting recovery from deep neuromuscular block by rocuronium in the elderly. J Clin Anesth 2003;15:328–333.PubMedCrossRefGoogle Scholar
  44. 44.
    d’Hollander AA, Luyckx C, Barvais L, et al. Clinical evaluation of atracurium besylate requirements for a stable muscle relaxation during surgery: lack of age-related effects. Anesthesiology 1983;59:237–240.PubMedGoogle Scholar
  45. 45.
    Kent AP, Parker CJ, Hunter JM. Pharmacokinetics of atracurium and laudanosine in the elderly. Br J Anaesth 1989; 63:661–666.PubMedCrossRefGoogle Scholar
  46. 46.
    Kitts JB, Fisher DM, Canfell PC, et al. Pharmacokinetics and pharmacodynamics of atracurium in the elderly. Anesthesiology 1990;72:272–275.PubMedCrossRefGoogle Scholar
  47. 47.
    Parker CJ, Hunter JM, Snowdon SL. Effect of age, sex and anesthetic technique on the pharmacokinetics of atracurium. Br J Anaesth 1992;69:439–443.PubMedCrossRefGoogle Scholar
  48. 48.
    Fisher DM, Canfell PC, Fahey MR, et al. Elimination of atracurium in humans: contribution of Hofmann elimination and ester hydrolysis vs. organ-based elimination. Anesthesiology 1986;65:6–12.PubMedCrossRefGoogle Scholar
  49. 49.
    Kisor DF, Schmith VD, Wargin WA, et al. Importance of the organ-independent elimination of cisatracurium. Anesth Analg 1996;83:1065–1071.PubMedCrossRefGoogle Scholar
  50. 50.
    Ornstein E, Lien CA, Matteo RS, et al. Pharmacodynamics and pharmacokinetics of cisatracurium in geriatric surgical patients. Anesthesiology 1996;84:520–525.PubMedCrossRefGoogle Scholar
  51. 51.
    Pühringer FK, Heier T, Dodgson M, et al. Double-blind comparison of the variability in spontaneous recovery of cisatracurium and vecuronium-induced neuromuscular block in adult and elderly patients. Acta Anesthesiol Scand 2002;46:364–371.CrossRefGoogle Scholar
  52. 52.
    Maddineni VR, Mirakhur RK, McCoy EP, et al. Neuromuscular and haemodynamic effects of mivacurium in elderly and young adult patients. Br J Anaesth 1994;73; 609–612.CrossRefGoogle Scholar
  53. 53.
    Goudsouzian N, Charravorti S, Denman W, et al. Prolonged mivacurium infusion in young and elderly adults. Can J Anaesth 1997;44:955–962.PubMedCrossRefGoogle Scholar
  54. 54.
    Østergaard D, Viby-Mogensen J, Pedersen NA, et al. Pharmacokinetics and pharmacodynamics of mivacurium in young adult and elderly patients. Acta Anaesthesiol Scand 2002;46:684–691.PubMedCrossRefGoogle Scholar
  55. 55.
    Maddineni VR, Mirakhur RK, McCoy EP. Plasma cholinesterase activity in elderly and young adults. Br J Anaesth 1994;72:497.PubMedCrossRefGoogle Scholar
  56. 56.
    Hart PS, McCarthy GJ, Brown R, Lau M, Fisher DM. The effect of plasma cholinesterase activity on mivacurium infusion rates. Anesth Analg 1995;80:760–763.PubMedCrossRefGoogle Scholar
  57. 57.
    Matteo RS, Young WL, Ornstein E, et al. Pharmacokinetics and pharmacodynamics of edrophonium in elderly surgical patients. Anesth Analg 1990;71:334–339.PubMedCrossRefGoogle Scholar
  58. 58.
    McCarthy GJ, Mirakhur RK, Maddineni VR, et al. Dose-responses for edrophonium during antagonism of vecuronium block in young and older adult patients. Anaesthesia 1995;50:503–506.PubMedCrossRefGoogle Scholar
  59. 59.
    Kitajima T, Ishii K, Ogata H. Edrophonium as an antagonist of vecuronium-induced neuromuscular block in the elderly. Anaesthesia 1995;50:359–361.PubMedCrossRefGoogle Scholar
  60. 60.
    Young WL, Backus W, Matteo RS, et al. Pharmacokinetics and pharmacodynamics of neostigmine in the elderly. Anesthesiology 1984;61:A300.CrossRefGoogle Scholar
  61. 61.
    McCarthy GJ, Cooper R, Stanley JC, et al. Dose-response relationships for neostigmine antagonism of vecuroniuminduced neuromuscular block in adults and the elderly. Br J Anaesth 1992;69:281–283.PubMedCrossRefGoogle Scholar
  62. 62.
    De Mey JC, Rolly G, Blauwen ND. Doxacurium block is not influenced by age. J Clin Anesth 1995;7:453–456.CrossRefGoogle Scholar
  63. 63.
    Young WL, Matteo RS, Ornstein E. Duration of action of neostigmine and pyridostigmine in the elderly. Anesth Analg 1988;67:775–778.PubMedGoogle Scholar
  64. 64.
    Kirkegaard H, Heier T, Caldwell JE. Efficacy of tactileguided reversal from cisatracurium-induced neuromuscular block. Anesthesiology 2002;96:45–50.PubMedCrossRefGoogle Scholar
  65. 65.
    Kopman AF, Yee PS, Neuman GG. Relationship of the train-of-four fade ratio to clinical signs and symptoms of residual paralysis in awake volunteers. Anesthesiology 1997; 86:765–771.PubMedCrossRefGoogle Scholar
  66. 66.
    Stone JG, Matteo RS, Ornstein E, et al. Aging alters the pharmacokinetics of pyridostigmine. Anesth Analg 1995; 81:773–776.PubMedCrossRefGoogle Scholar
  67. 67.
    Cronnelly R, Stanski DR, Miller RD, et al. Pyridostigmine kinetics with and without renal function. Clin Pharmacol Ther 1980;28:78–81.PubMedGoogle Scholar
  68. 68.
    Muravchick S, Owens WD, Felts JA. Glycopyrrolate and cardiac dysrhythmias in geriatric patients after reversal of neuromuscular blockade. Can Anaesth Soc J 1979;26: 22–25.PubMedGoogle Scholar
  69. 69.
    Owens WD, Waldbaum LS, Stephen CR. Cardiac dysrhythmias following reversal of neuromuscular blocking agents in the geriatric patient. Anesth Analg 1978;57:186–190.PubMedGoogle Scholar
  70. 70.
    Simpson KH, Smith RJ, Davies LF. Comparison of the effects of atropine and glycopyrrolate on cognitive function following general anesthesia. Br J Anaesth 1987;59:966–969.PubMedCrossRefGoogle Scholar
  71. 71.
    Baraka A, Yared JP, Karam AM, et al. Glycopyrrolateneostigmine and atropine-neostigmine mixtures affect postanesthesia arousal times differently. Anesth Analg 1980;59: 431–434.PubMedCrossRefGoogle Scholar
  72. 72.
    Berg H, Viby-Mogensen J, Roed Mortensen CR, et al. Residual neuromuscular block is a risk factor for postoperative pulmonary complications: a prospective, randomized and blinded study of postoperative complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand 1997;41:1095–1103.PubMedGoogle Scholar
  73. 73.
    Lunn JN, Hunter AR, Scott DB. Anaesthesia-related surgical mortality. Anaesthesia 1983;38:1090–1096.PubMedCrossRefGoogle Scholar
  74. 74.
    Cooper AL, Leigh JM, Tring IC. Admissions to the intensive care unit after complications of anesthetic techniques over 10 years. Anaesthesia 1989;44:953–958.PubMedCrossRefGoogle Scholar
  75. 75.
    Tiret L, Nivoche Y, Hatton F, Desmonts JM, Vourch G. Complications related to anesthesia in infants and children: a prospective survey in 40,240 anaesthetics. Br J Anaesth 1988;61:263–269.PubMedCrossRefGoogle Scholar
  76. 76.
    Eriksson LI, Sundman E, Olsson R, et al. Functional assessment of the pharynx at rest and during swallowing in partially paralyzed humans: simultaneous videomanometry and mechanomyography of awake human volunteers. Anesthesiology 1997;87:1035–1043.PubMedCrossRefGoogle Scholar
  77. 77.
    Sundman E, Witt H, Olsson R, et al. The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and simultaneous manometry after atracurium. Anesthesiology 2000;92:977–984.PubMedCrossRefGoogle Scholar
  78. 78.
    Wyon N, Joensen H, Yamamoto Y, Lindahl SG, Eriksson LI. Carotid body chemoreceptor function is impaired by vecuronium during hypoxia. Anesthesiology 1998;89:1471–1479.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Cynthia A. Lien
    • 1
  • Takahiro Suzuki
    • 2
  1. 1.Department of AnesthesiologyWeill Medical College of Cornell UniversityNew YorkUSA
  2. 2.Department of AnesthesiologyNihon University Surugadai HospitalTokyoJapan

Personalised recommendations