Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA.
Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code: UHN-2, Portland, OR, 97239-3098, USA.
Drugs Aging. 2022 Oct;39(10):749-761. doi: 10.1007/s40266-022-00969-4. Epub 2022 Aug 8.
Residual neuromuscular paralysis, the presence of clinically significant weakness after administration of pharmacologic neuromuscular blockade reversal, is associated with postoperative pulmonary complications and is more common in older patients. In contemporary anesthesia practice, reversal of neuromuscular blockade is accomplished with neostigmine or sugammadex. Neostigmine, an acetylcholinesterase inhibitor, increases the concentration of acetylcholine at the neuromuscular junction, providing competitive antagonism of neuromuscular blocking drug and facilitating muscle contraction. Sugammadex, a modified gamma-cyclodextrin, antagonizes neuromuscular blockade by encapsulating rocuronium and vecuronium in a one-to-one ratio for renal clearance, a pharmacokinetic property that led to the recommendation that sugammadex not be administered to those with end-stage renal disease. While data are limited, reports suggest sugammadex is efficacious and well tolerated in individuals with reduced renal function. Sugammadex provides a more rapid and complete reversal of neuromuscular blockade than neostigmine. There is also accumulating evidence that sugammadex may provide a protective effect against the development of postoperative pulmonary complications, nausea, and vomiting, and that it may have beneficial effects on the rate of bowel and bladder recovery after surgery. Accordingly, sugammadex administration is beneficial for most older patients undergoing surgery.
残余神经肌肉阻滞，即使用药物逆转神经肌肉阻滞后仍存在临床显著的肌无力，与术后肺部并发症有关，并且在老年患者中更为常见。在当代麻醉实践中，使用新斯的明或琥珀酰明碱来逆转神经肌肉阻滞。新斯的明是一种乙酰胆碱酯酶抑制剂，可增加神经肌肉接头处乙酰胆碱的浓度，提供对神经肌肉阻滞药物的竞争性拮抗作用，并促进肌肉收缩。琥珀酰明碱是一种改良的γ-环糊精，通过以 1:1 的比例将罗库溴铵和维库溴铵包裹在其中来拮抗神经肌肉阻滞，这种药代动力学特性导致建议在终末期肾病患者中不使用琥珀酰明碱。虽然数据有限，但报告表明琥珀酰明碱在肾功能降低的个体中是有效且耐受良好的。琥珀酰明碱比新斯的明能更迅速和完全地逆转神经肌肉阻滞。也有越来越多的证据表明，琥珀酰明碱可能对术后肺部并发症、恶心和呕吐的发生具有保护作用，并且可能对术后肠道和膀胱恢复的速度有有益影响。因此，琥珀酰明碱的给药对大多数接受手术的老年患者有益。
