de Almeida M C, Latorre F, Gervais H W, Kleeman P P
Klinik für Anästhesiologie, Johannes Gutenberg-Universität Mainz.
Anaesthesist. 1996 Oct;45(10):903-6. doi: 10.1007/s001010050324.
Elderly patients may show an age-related decline in physiologic functions, which may be responsible for the prolonged duration of some neuromuscular blocking agents. Previous studies have yielded conflicting results as to the effects of these drugs in the elderly.
After obtaining informed consent and approval of the Ethics Committee, we compared onset and recovery times of single IV doses of atracurium, rocuronium, and vecuronium given to 108 patients divided into three groups according to age (18-50, 51-64, > or = 65 years). Following oxazepam premedication and fentanyl and thiopentone induction, patients were randomly allocated to receive atracurium, rocuronium or vecuronium (0.5, 0.6, or 0.1 mg/kg, respectively) in < or = 0.8 vol.% enflurane (end-tidal)-nitrous oxide anaesthesia. Muscular relaxation was assessed by electromyographic (EMG) recording of the adductor pollicis muscle after supramaximal single-twitch stimulation of the ulnar nerve every 10 s. Onset time and recovery to 25%, 75% and 90% of twitch control values (DUR25, 75, 90) were recorded. Creatinine clearance predicted from serum creatinine (Ccr) was correlated with recovery from neuromuscular block.
Onset time was not different among groups or relaxants. The results showed a prolonged duration of action for atracurium (DUR75, DUR90), rocuronium (DUR25, DUR75), and vecuronium (DUR25) in the elderly. A number of patients did not reach DUR75 or DUR90. There was a significant relationship between age and failure to return to control values during recovery from neuromuscular block, especially after atracurium and rocuronium. Ccr showed a negative correlation with age for all relaxants, but a negative significant correlation between Ccr and recovery was found only for rocuronium.
This study suggests that onset time for atracurium, rocuronium and vecuronium is not age-dependent. Recovery was prolonged in the elderly for all three relaxants. This effect appears to be secondary to changes in body composition and function accompanying the aging process. Neither atracurium nor vecuronium depends significantly on the kidney for elimination, but the negative correlation between Ccr and rocuronium suggests an appreciable role for the kidney in the elimination of this relaxant. The long recovery times observed in this study could also be related to enflurane anaesthesia. We suggest that failure of EMG responses to return to baseline values during recovery from neuromuscular block may be related to age, especially for atracurium and rocuronium.
老年患者可能会出现与年龄相关的生理功能衰退，这可能是某些神经肌肉阻滞剂作用时间延长的原因。以往关于这些药物对老年人影响的研究结果相互矛盾。
在获得知情同意并经伦理委员会批准后，我们将108例患者按年龄分为三组（18 - 50岁、51 - 64岁、≥65岁），比较单次静脉注射阿曲库铵、罗库溴铵和维库溴铵的起效时间和恢复时间。在给予奥沙西泮进行术前用药以及芬太尼和硫喷妥钠诱导后，患者被随机分配接受阿曲库铵、罗库溴铵或维库溴铵（分别为0.5、0.6或0.1mg/kg），采用≤0.8%体积分数的安氟醚（呼气末）-氧化亚氮麻醉。每隔10秒对尺神经进行超强单刺激后，通过对拇内收肌进行肌电图（EMG）记录来评估肌肉松弛情况。记录起效时间以及恢复至单次抽搐控制值的25%、75%和90%时的时间（DUR25、75、90）。根据血清肌酐（Ccr）预测的肌酐清除率与神经肌肉阻滞的恢复情况相关。
各年龄组和不同肌松药之间的起效时间无差异。结果显示，老年人中阿曲库铵（DUR75、DUR90）、罗库溴铵（DUR25、DUR75）和维库溴铵（DUR25）的作用时间延长。许多患者未达到DUR75或DUR90。年龄与神经肌肉阻滞恢复过程中未恢复至控制值之间存在显著关系，尤其是在使用阿曲库铵和罗库溴铵后。对于所有肌松药，Ccr与年龄呈负相关，但仅罗库溴铵的Ccr与恢复情况呈显著负相关。
本研究表明，阿曲库铵、罗库溴铵和维库溴铵的起效时间不依赖于年龄。所有三种肌松药在老年人中的恢复时间均延长。这种效应似乎是衰老过程中身体成分和功能变化的继发结果。阿曲库铵和维库溴铵的消除均不显著依赖于肾脏，但Ccr与罗库溴铵之间的负相关表明肾脏在消除这种肌松药方面起重要作用。本研究中观察到的较长恢复时间也可能与安氟醚麻醉有关。我们认为，在神经肌肉阻滞恢复过程中肌电图反应未能恢复至基线值可能与年龄有关，尤其是对于阿曲库铵和罗库溴铵。
