Management of Neuromuscular Blockade in the Elderly and Morbidly Obese Patient: What Does the Data Show?

AbstractPurpose of ReviewThis review addresses considerations for optimal neuromuscular blockade management in the elderly and obese. The evidence for adjusting dosing for common neuromuscular blocking drugs (NMBDs) and their antagonists are discussed.Recent FindingsIn the elderly patient, aminosteroidal NMBDs have a slower onset and prolonged duration of action. Aging has minimal effects on the organ-independent metabolism of the benzylisoquinolinium NMBDs. Slower circulatory times and reduced renal function in the elderly also have implications on the clinical effects of NMBD antagonists. Since drug clearance and distribution is not the same in obese and in lean patients, dosing based on the total body weight (TWB) will result in excess NMBD administration. Various dosing scalars such as ideal body weight (IBW), lean body weight (LBW), and fat-free mass (FFM) have been proposed but each has its own limitations. NMBDs should be dosed based on ideal body weight in obese patients. Optimal sugammadex dosing in obese patients remains controversial while neostigmine administration should not exceed 5  mg.SummaryElderly and obese patients have an increased risk of developing complications in the perioperative period, particularly when NMBDs are administered. Vigilance, careful titration, and quantitative monitoring are warranted to care for these challenging patients.

Source: Current Anesthesiology Reports - March 5, 2020 Category: Anesthesiology Source Type: research