Comparison of neostigmine and sugammadex following desflurane and total intravenous anesthesia in the elderly

Purpose: The aim of this study is to compare the effects of neostigmine and sugammadex on the post-anesthesia awakening and muscle strength following desflurane and TIVA anesthesia applied to patients older than 65 years of age. Materials and Methods: This study is accomplished after obtaining informed consent forms from patients and with the approvals of the Ethics Committee and the Anesthesiology and Reanimation Department of the Cukurova University Medical Faculty. 80 patients above 65 years of age, having an ASA status between 1 to 3 and with a predicted operation time not exceeding 150 minutes were included to the study. Patients randomized with simple indiscriminate methodology were divided into four groups. The first group received TIVA+sugammadex (Group –I), the second group received TIVA+neostigmine (Group –II), the third group received desflurane+sugammadex (Group –III) and the fourth group received desflurane+neostigmine (Group –IV), respectively. TIVA solution was prepared using 260 mg of propofol, 1.3 mg of remifentanil and 50 mg of lidocaine dissolved in 100 ml's of isotonic solution. For anesthesia induction, all patients were applied thiopental (5-7 mg/kg) and rocuronium (0.5 mg/kg) intravenously and endotracheal entubation was provided. Perpetual stage of anesthesia was achieved with combination of oxygen (33%)+ nitrogen protoxide/nitrous oxide (67%) and TIVA in Group-I and Group-II. Perpetual anesthesia was achieved with combination of oxygen (33%)+ nitrogen protoxide/nitrous oxide (67%) and desflurane in Group-III and Group-IV. For terminating the anesthesia procedure, patients were switched to oxygen (100%) after cessation of TIVA, desflurane and N2O while the last skin sutures were closured. The neuromuscular block level was monitored by the train-of-four (TOF) stimulation. Additional rocuronium (0.1-0.2 mg per kg) was given when TOF value reached 3 during measurements of TOF throughout the operation. At the end of the surgery, when a TOF value of 2 was achieved, sugammadex was applied (2 mg/kg) to the Group-I and –III and neostigmine (50 µg/kg) and atropine (20 µg/kg) were applied to the Group-II and IV, respectively. Monitorization of the depth of anesthesia was accomplished by providing the connection of the bispectral index (BIS) sensor positioned on the frontotemporal region with the bispectral index monitor. Anesthesic agent concentrations were adjusted to arrange BIS values between 40 to 60. Awakening from anesthesia was evaluated by the modified Aldrette Scor (MAS). Conclusion: It is concluded that when neostigmine or sugammadex were applied for decurarization after general anesthesia with desflurane or TIVA in elderly patients, sugammadex significantly reduced the recovery time of the neuromuscular block independent of the anesthesia type, spontaneous respiration recovered in TIVA-applied cases and caused higher BIS levels during extubation. Key Words: Desflurane, TIVA, neostigmine, sugammadex, geriatric anesthesia, cognitive functioning