renal failure/ESRD sugammadex/roc or cisatracurium/neo-glyco

[GaseousClay]

i know sugam is renally cleared but some people i know say this works with even dialysis patients much better than cis/neo-glyco. less residual blockade. anyone else use roc/sugam for renal failure patients?

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[nimbus]

i know sugam is renally cleared but some people i know say this works with even dialysis patients much better than cis/neo-glyco. less residual blockade. anyone else use roc/sugam for renal failure patients?

Yes sugammadex works great in renal failure patients. Complete and total reversal.

 

[Ronin786]

I don't fully understand the caution with regards to sugammadex and renal failure. The NDMB-Sugammadex complexes should take longer to be excreted, but they're still not bound on the NMJ. Shouldn't that still ensure full reversal?

 

[RK.md]

I don't fully understand the caution with regards to sugammadex and renal failure. The NDMB-Sugammadex complexes should take longer to be excreted, but they're still not bound on the NMJ. Shouldn't that still ensure full reversal?

Agree with this. Probably more of a precautionary measure by Merck.

 

[deleted162650]

I don't fully understand the caution with regards to sugammadex and renal failure. The NDMB-Sugammadex complexes should take longer to be excreted, but they're still not bound on the NMJ. Shouldn't that still ensure full reversal?

My guess is that they are afraid the complexes will hang out in circulation long enough to start dissociating to some degree.

 

[AdmiralChz]

My guess is that they are afraid the complexes will hang out in circulation long enough to start dissociating to some degree.

Also if you needed to reparalyze for an emergent bring back, would it be an issue?

 

[pgg]

Also if you needed to reparalyze for an emergent bring back, would it be an issue?

Use a non-steroid NMBD like cis.

 

[AdmiralChz]

Use a non-steroid NMBD like cis.

Yeah, we don't readily have cis or even atracurium around our main ORs (have to be specially ordered from pharmacy, probably not fast enough in a true emergency) - so some cases we avoid sugammadex.

 

[BLADEMDA]

Sugammadex works just fine with Renal Failure Patients as long as you utilize Hi Flux Dialysis to remove the bound substrate.



https://oup.silverchair-cdn.com/oup...rctuWSJcvQ__&Key-Pair-Id=APKAIUCZBIA4LVPAVW3Q
http://msl1.mit.edu/ESD10/kidneys/HndbkHTML/ch3.htm

 

[BLADEMDA]

 

[Consigliere]

Problem is though we just can't seem to generate the requisite 1.21 gigawatts of power nor can we get the patient's bed up to 88 mph.

 

[facted]

Roc, neo glyco works just fine. Just saying.

 

[pgg]

Roc, neo glyco works just fine. Just saying.

Neostigmine is cleared renally too. Just saying.

It doesn't matter. But given the choice, I would opt for sugammadex for reversal every time. Neostigmine is a dirty drug.

 

[facted]

Neostigmine is cleared renally too. Just saying.

It doesn't matter. But given the choice, I would opt for sugammadex for reversal every time. Neostigmine is a dirty drug.

and the last time you clinically had an issue because of neo in a renal patient was.....

 

[pgg]

and the last time you clinically had an issue because of neo in a renal patient was.....

Never

It doesn't matter.

 

[nimbus]

Roc, neo glyco works just fine. Just saying.

Suga works better....just takes a little longer. Especially if you accidentally overdose the roc. Just my personal experience.

 

[periopdoc]

Sugammadex takes longer? This is a joke right?

 

[sevoflurane]

Love, love the sugga. Best drug out there since propofol. Meh on glyco/neo nowadays for me. They are the new bastard child of my armamentarium.

Not to hijack this thread or anything but what is the deal with renal patients always getting NS?

Say you take a patient back with a K of 5.2. Someone please convince me of why I need to give NS over LR in renal failure patients who are on dyalysis.
I've never really understood this... but maybe I'm missing something.

 

[deleted162650]

Love, love the sugga. Best drug out there since propofol. Meh on glyco/neo nowadays for me. They are the new bastard child of my armamentarium.

Not to hijack this thread or anything but what is the deal with renal patients always getting NS?

Say you take a patient back with a K of 5.2. Someone please convince me of why I need to give NS over LR in renal failure patients who are on dyalysis.
I've never really understood this... but maybe I'm missing something.

We had a good thread on this topic a while ago (probably at least a year or two now). I agree - NS is stupid.

As for sugga, eh - kind of a nurse drug isn't it?

 

[pgg]

As for sugga, eh - kind of a nurse drug isn't it?

Yeah, totally like styleting an endotracheal tube or using desflurane or remifentanil.

 

[Mman]

Problem is though we just can't seem to generate the requisite 1.21 gigawatts of power nor can we get the patient's bed up to 88 mph.

you've never seen our PACU nurses when they finally get a bed assignment for an ICU boarder, I think I've seen smoke from the bed wheels from the rapid rate of acceleration down the hallway.

 

[Consigliere]

you've never seen our PACU nurses when they finally get a bed assignment for an ICU boarder, I think I've seen smoke from the bed wheels from the rapid rate of acceleration down the hallway.

True. I forgot about the speed with which our RNs exit the hospital 5 minutes before the end of their shift. I mean, their yard wide asses have been one with the rolling chair for 8 hours but when it's time to go, they morph into Usain Bolt.

 

[Twiggidy]

Love, love the sugga. Best drug out there since propofol. Meh on glyco/neo nowadays for me. They are the new bastard child of my armamentarium.

Not to hijack this thread or anything but what is the deal with renal patients always getting NS?

Say you take a patient back with a K of 5.2. Someone please convince me of why I need to give NS over LR in renal failure patients who are on dyalysis.
I've never really understood this... but maybe I'm missing something.

i think it's mostly out of old habits and the old habits that always worked get taught to the new folks, whereas we all know you're likely correct, it really doesnt matter.

 

[ranvier]

The looks I get if I bring an ICU bound patient to PACU for whatever reason....it's 9 floors away, they really aren't sick just have a flap, or god forbid I want them to actually do a little pacu recovery before hitting the unit.

 

[nimbus]

Sugammadex takes longer? This is a joke right?

I should have been clearer. Suga takes longer to work in a dialysis patient vs a normal patient. It doesn't take longer than neostig.

 

[Robotic Wis-Hipple]

Love, love the sugga. Best drug out there since propofol. Meh on glyco/neo nowadays for me. They are the new bastard child of my armamentarium.

Not to hijack this thread or anything but what is the deal with renal patients always getting NS?

Say you take a patient back with a K of 5.2. Someone please convince me of why I need to give NS over LR in renal failure patients who are on dyalysis.
I've never really understood this... but maybe I'm missing something.

There's actually data saying NS is worse for K+ due to acidosis causing shift of intracellular K+ and may actually increase risk for AKI/renal malperfusion.

https://www.ncbi.nlm.nih.gov/m/pubmed/15845718/

http://jamanetwork.com/journals/jama/fullarticle/1383234#Abstract

https://www.ncbi.nlm.nih.gov/m/pubmed/22580944/

 

[Planktonmd]

Not to hijack this thread or anything but what is the deal with renal patients always getting NS?

Say you take a patient back with a K of 5.2. Someone please convince me of why I need to give NS over LR in renal failure patients who are on dyalysis.
I've never really understood this... but maybe I'm missing something.

The explanation is old nursing urban legend and fear of clipboard jockeys!

 

[Psai]

Love, love the sugga. Best drug out there since propofol. Meh on glyco/neo nowadays for me. They are the new bastard child of my armamentarium.

Not to hijack this thread or anything but what is the deal with renal patients always getting NS?

Say you take a patient back with a K of 5.2. Someone please convince me of why I need to give NS over LR in renal failure patients who are on dyalysis.
I've never really understood this... but maybe I'm missing something.

Because when your patient has a k of 5.2 and you give a fluid with a k of 4, it will increase the k in the blood
That's how dilution works.

 

[drmwvr]

Would that there were as much hand wringing over giving NS for volume replacement at all.

 

[Gaseous Clay]

I still use neo/glyco in my ESRD pts on HD because it is not recommended to use Sugammadex by Merck. Since the drug is mainly renally excreted, there is concern that the potential side effects of the drug can linger for much longer (2 hours normal elim half life vs a 17x increase in ESRD). As Blade said, hi flux HD is the only sure way to remove it but I don't believe it's routine for HD centers to perform that and not sure how capable they are. Do you want to be the one responsible for calling your patient's dialysis center and making sure they're setup for hi flux? Would you plan to do that immediately post op or are you comfortable sending them home that night for HD the next day?

As I often hear, don't be the first to do something but also don't be the last. I know we do a lot of things off label but until this becomes routine practice around the country and world, I'll be sticking to the company's recommendation for now.

 

[deleted171991]

Not to hijack this thread or anything but what is the deal with renal patients always getting NS?

Say you take a patient back with a K of 5.2. Someone please convince me of why I need to give NS over LR in renal failure patients who are on dyalysis.
I've never really understood this... but maybe I'm missing something.

You're not missing anything.

NS is about as normal and physiologic as high fructose corn syrup. NS-induced hyperchloremic metabolic acidosis will bump the K much more than the equivalent volume of LR. I guess some people have never heard of hyperkalemia secondary to metabolic acidosis.