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Sugammadex may be the best available drug to reverse residual neuromuscular blockade produced by rocuronium and vecuroniumA 5% incidence of residual neuromuscular blockade has been reported after administering sugammadex without neuromuscular monitoringElderly patients have been reported to respond differently than nonelderly patients do to rocuronium and sugammadexThe train-of-four ratio recovery rate after low-dose sugammadex administration was slower in elderly patients than it was in nonelderly patientsRecurarization after low-dose sugammadex administration occurred more frequently in elderly patients than in nonelderly patientsSlower spontaneous train-of-four ratio recovery and impaired renal function were most closely associated with the decreased train-of-four ratio change rate in response to low-dose sugammadex in multiple linear regression analysisComplete recovery from rocuronium-induced muscle paralysis with sugammadex is reported to be delayed in elderly patients. The authors tested a hypothesis that recovery from deep neuromuscular block with low-dose sugammadex is slower (primary hypothesis) and incidence of recurarization is higher (secondary hypothesis) in elderly patients than in nonelderly patients.In anesthetized elderly (n = 20; 76.9 ± 5.0 yr of age) and nonelderly patients (n = 20; 53.7 ± 12.8 yr of age) under deep paralysis with rocuronium, change of train-of-four ratio per minute (primary outcome variable) was measured with an acceleromyograph neuromuscular monitor during spontaneous recovery from rocuronium-induced muscle paralysis (0.6 mg/kg) and after infusion of low-dose sugammadex (50 µg · kg-1 · min-1). Recurarization was defined as the negative change of train-of-four ratio.Spontaneous train-of-four ratio recovery rate was significantly slower in the elderly group (median [25th percentile, 75th percentile]: 1.89 [1.22, 2.90] %/min) than in the nonelderly group (3.45 [1.96, 4.25] %/min, P = 0.024). Train-of-four ratio change rate in response to low-dose sugammadex was significantly slower in elderly (0.55 [–0.29, 1.54] %/min) than in the nonelderly group (1.68 [0.73, 3.13] %/min, P = 0.024). Incidence of recurarization was significantly higher in the elderly group than in the nonelderly group (35% vs. 5%, P = 0.044). Multiple linear regression analyses indicate that slower spontaneous train-of-four ratio recovery rate and impaired renal function are two major contributing factors that decrease train-of-four ratio change rate in response to low-dose sugammadex.Elderly patients are at greater risk for recurarization and residual muscle paralysis when low-dose sugammadex is administered.