I was thinking that too, then wondering if she was in the same position that I am right now... no sux available.
Who do you sue then? Pharmacy for not obtaining it from alternate sources? The manufacturer? The FDA?
Of course I realize it would be the anesthesiologists for proceeding with the procedure "without necessary safety medications," but it reminds me just how precarious a situation some of us are in right now.
Anyone know just how quickly that 2 mg/kg Roc dose achieves intubating conditions?
- pod
Succinylcholine (Sch) and rocuronium (ROC) are both recommended for rapid sequence induction intubation. The onset, extent, and duration of muscle paralysis are dose-dependent.
Pharmacodynamic studies suggest the effective dose (ED
95) for succinylcholine is 0.3 mg/kg; adequate muscle relaxation may take 120 seconds.
[1] Naguib and colleagues
[2] randomized 180 patients to variable doses of Sch following fentanyl and propofol induction. They found that excellent intubation conditions at 50 seconds were obtained in 80% of patients with 1.5 mg/kg vs only 63% with 1.0 mg/kg Sch. The durations of action were 7.2 and 5.9 minutes, respectively.
[2] Another study found that reducing Sch dose by 40% (from 1.0 mg/kg to 0.6 mg/kg) hastened muscle recovery by 90 seconds.
[3] The superior intubation conditions achieved with the 1.5-mg/kg dose of Sch trumps any concern about this minimal increase in duration of action. Finally, muscle fasciculations and myalgias are less pronounced with 1.5 mg/kg dose than with lower doses.
[4] Although some providers advocate for larger doses of Sch, such as 2 mg/kg, there is no pharmacologic or clinical rationale for this dosage increase in adults based on anecdotal experience. The best dose of Sch for emergency intubation is 1.5 mg/kg.
ROC is the preferred muscle relaxant when there are contraindications to Sch. A randomized study of patients using various doses of ROC identified 1 mg/kg as the dose necessary to achieve intubation in 60 seconds in 95% of patients.
[5] Another randomized study of 349 patients also found that 0.6 mg/kg of ROC was inferior to 1 mg/kg.
[6] In the emergency setting, achieving excellent intubation conditions reliably and early is paramount, arguing convincingly for the 1 mg/kg dose.
Two recent large meta-analyses containing only controlled trials showed that both clinically excellent and acceptable intubation conditions are more likely with succinylcholine compared to 0.6-0.8 mg/kg of ROC, independent of the induction agent. High-dose ROC (1.0-1.2 mg/kg) was statistically similar to Sch; however, the prolonged duration of action of ROC argues in favor of SCh as the drug of choice for emergency rapid sequence induction intubation, unless contraindications exist.
[7,8]
While most drugs are dosed by total body weight (TBW) for normal-sized adults, morbidly obese patients are often dosed based on their "ideal" body weightor by "lean" body weight. Lean body weight adds 30% of the total weight increase (over ideal body weight) to account for increased intravascular and tissue volume. When dosed by TBW, succinylcholine has activity in obese adolescents equivalent to TBW dosing in nonobese controls.
[9] A study of 45 morbidly obese patients undergoing bariatric surgery found that intubation conditions were superior in patients randomized to TBW vs ideal body weight dosing.
[10]
There are few studies of ROC in morbidly obese patients, but most show a prolongation of the duration of action.
[11,12] One study of patients with body mass index > 40 kg/m
2 found that recovery to 25% of full muscle twitch tension was more than doubled (55 vs 22 minutes,
P < .001) when TBW dosing was used vs ideal body weight. Time to onset of muscle relaxation, however, was not statistically different (77 vs 87 seconds).
[13]
