Sugammadex now recommended per ASA

[deleted875186]

Nope. You still are not supposed to remove the endotracheal tube until the patient meets criteria for extubation. Extubating a weak patient was bad care before suggamadex came out. That is how it will play out.

I believe he is referring to the instance of induction with rocuronium and cannot ventilate and cannot intubate, in which case immediate access to rocuronium is life saving, and placing rocuronium out of the OR is a lawsuit.

---

Members don't see this ad.

 

[Dr. Rude]

I believe he is referring to the instance of induction with rocuronium and cannot ventilate and cannot intubate, in which case immediate access to rocuronium is life saving, and placing rocuronium out of the OR is a lawsuit.

More plausible. But I still think that that the blame would fall on the practitioner for failing to recognize or manage a difficult airway. If the ASA would update their difficult airway algorithm to mention suggamadex, that would go a long way to always having it immediately available and maybe have the hospital eat part of a bad outcome lawsuit if it wasn’t.

 

[epidural man]

More plausible. But I still think that that the blame would fall on the practitioner for failing to recognize or manage a difficult airway. If the ASA would update their difficult airway algorithm to mention suggamadex, that would go a long way to always having it immediately available and maybe have the hospital eat part of a bad outcome lawsuit if it wasn’t.

I dont care if the anesthesiologist made a bunch of bad decisions. No previous bad decision can ever excuse the bean counter decision to not having a potential life saving $50 solution readily available.

 

[2Fast2Des]

My old co-fellow in fellowship thought they were being clever and gave just neostigmine and no glyco to a patient that had a heart transplant several years prior because the heart was denervated so they couldn’t get bradycardia/asystole. The patient **** themselves on the table. Never got bradycardic though.

My senior colleague used to tell me they did this when the urologist was a douche and to give some underhanded payback they would give neo and watch the glorious karma as the pt was ****ting in their face

 

[Dr. Rude]

My senior colleague used to tell me they did this when the urologist was a douche and to give some underhanded payback they would give neo and watch the glorious karma as the pt was ****ting in their face

Damn. I wish I had thought of that a few decades ago.

 

[pgg]

If a patient is having an anaphylaxis reaction to roc or vec, would suggamadex help?

Interesting question - I bet it would. You're removing the offending antigen from circulation by chelating it.

 

[cincincyreds]

2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade

These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents during and after general anesthesia. The guidance focuses primarily on the type and site of monitoring and the process of antagonizing...

pubs.asahq.org

Sugammadex is recommended from deep, moderate, and shallow levels of neuromuscular blockade that is induced by rocuronium or vecuronium. Neostigmine is a reasonable alternative from minimal blockade (train-of-four ratio in the range of 0.4 to less than 0.9). Patients with adequate spontaneous recovery to train-of-four ratio greater than or equal to 0.9 can be identified with quantitative monitoring, and these patients do not require pharmacological antagonism.

Finding this stuff at work is like finding raiders of the lost ark. Anyway I'll document now in the chart pharmacy refuses to supply appropriate medication per guidelines.

 

[Dr. Rude]

Finding this stuff at work is like finding raiders of the lost ark. Anyway I'll document now in the chart pharmacy refuses to supply appropriate medication per guidelines.

If you really want to stir the pot- send pharmacy an email and that you are prepared to list the director of Pharmacy as the cause of death on the death certificate in the event of a death.

 

[lotsapain]

Just use a soft bite block. Poor technique for emergence shouldn't be a reason to restrict sugammadex use/access

That has absolutely nothing to do with it.

 

[lotsapain]

Please explain. So patient has an ETT, is reversed, and then what bites on the tube? Seems more related to poor technique rather than the drug.

The cases happen after extubating actually. This is secondary to large inspiratory forces created by fast reversal while the pharyngeal muscle may not be fully recovered. What I see is that many providers now get away from using a twitch monitor which is still an important tool even with Suggamadex as it dictates dosing and timing. Suggamadex is not a solution to be less vigilant, I have seen CRNAs (and MDs) give it like water without really thinking... ie an hour has passed I will just give it at 2mg/kg.....

Negative Pressure Pulmonary Edema after Reversing Rocuronium-Induced Neuromuscular Blockade by Sugammadex

Negative pressure pulmonary edema (NPPE) is a rare complication that accompanies general anesthesia, especially after extubation. We experienced a case of negative pressure pulmonary edema after tracheal extubation following reversal of rocuronium-induced ...

www.ncbi.nlm.nih.gov

Yes indeed, appropriate extubation technique is essential.

 

[lotsapain]

Nope. You still are not supposed to remove the endotracheal tube until the patient meets criteria for extubation. Extubating a weak patient was bad care before suggamadex came out. That is how it will play out.

WOW just WOW to the original poster

It absolutely will go away after a single lawsuit….which is coming.

Most of us would GLADLY sit on the stand for the prosecution and say “yes, this lost airway and death could have been 100% avoided had the pharmacy not been stingy and placed the only drug that would help in the cart. It is the hospital’s greed that killed this patient. The anesthesiologist’s hands were tied by administrators. And might I add, MOST hospitals make it immediately available.” Yeah…keeping it outside the OR is a big payout waiting to happen.

In the last 20 years or more in this field, nothing has changed or really advanced, except for two things: suggamadex and video laryngoscopy. To ignore the first is risky.

I mean this just blows my mind as Dr. Rude said if you removed an airway on a weak patient and then blame pharmacy for your stupidity your license will disappear very quickly. No none of us will say on the stand that "I removed the tube to prove that pharmacy is cheap" Cannot make this stuff up

 

[deleted875186]

The cases happen after extubating actually. This is secondary to large inspiratory forces created by fast reversal while the pharyngeal muscle may not be fully recovered. What I see is that many providers now get away from using a twitch monitor which is still an important tool even with Suggamadex as it dictates dosing and timing. Suggamadex is not a solution to be less vigilant, I have seen CRNAs (and MDs) give it like water without really thinking... ie an hour has passed I will just give it at 2mg/kg.....

Negative Pressure Pulmonary Edema after Reversing Rocuronium-Induced Neuromuscular Blockade by Sugammadex

Negative pressure pulmonary edema (NPPE) is a rare complication that accompanies general anesthesia, especially after extubation. We experienced a case of negative pressure pulmonary edema after tracheal extubation following reversal of rocuronium-induced ...

www.ncbi.nlm.nih.gov

Yes indeed, appropriate extubation technique is essential.

That case report was a case of laryngospasm after extubation, somehow blamed on suggamadex without any supporting evidence or rationale. I’m surprised it got published.

 

[lotsapain]

That case report was a case of laryngospasm after extubation, somehow blamed on suggamadex without any supporting evidence or rationale. I’m surprised it got published.

I am giving you examples, there are plenty more with tube in place

 

[deleted875186]

I am giving you examples, there are plenty more with tube in place

But there is no way to logically explain negative pressure pulmonary edema occurring with a tube in place.

Unless your saying pulmonary edema is occurring from some other mechanism from suga.

 

[lotsapain]

But there is no way to logically explain negative pressure pulmonary edema occurring with a tube in place.

Unless your saying pulmonary edema is occurring from some other mechanism from suga.

There is, rapid reversal of paralysis resulting in rapidly increasing respiratory force. I am sure you have seen negative pressure pulmonary edema in large athletes / bodybuilder with tube in place which is the most common scenario.

 

[anaesthetic]

The cases happen after extubating actually. This is secondary to large inspiratory forces created by fast reversal while the pharyngeal muscle may not be fully recovered. What I see is that many providers now get away from using a twitch monitor which is still an important tool even with Suggamadex as it dictates dosing and timing. Suggamadex is not a solution to be less vigilant, I have seen CRNAs (and MDs) give it like water without really thinking... ie an hour has passed I will just give it at 2mg/kg.....

Negative Pressure Pulmonary Edema after Reversing Rocuronium-Induced Neuromuscular Blockade by Sugammadex

Negative pressure pulmonary edema (NPPE) is a rare complication that accompanies general anesthesia, especially after extubation. We experienced a case of negative pressure pulmonary edema after tracheal extubation following reversal of rocuronium-induced ...

www.ncbi.nlm.nih.gov

Yes indeed, appropriate extubation technique is essential.

Not really convinced that the post-extubation laryngospasm was caused by rapid administration of sugammadex. Anyone with adequate/complete neuromuscular blockade reversal could generate enough negative inspiratory force to cause NPPE.

Lots of other possible causes: extubation during “stage 2” (if it exists), secretions/mucous, inadequate deflation of the ETT balloon, poor extubation technique, airway reactivity, etc.

Sugammadex is a good drug, IMO, and probably superior to neo/glyco based on current data. That being said, agreed overall that it’s not an excuse to be less vigilant or critical of its limitations. Same with any other drug.

 

[Arch Guillotti]

There is, rapid reversal of paralysis resulting in rapidly increasing respiratory force. I am sure you have seen negative pressure pulmonary edema in large athletes / bodybuilder with tube in place which is the most common scenario.

I have never seen this.

 

[lotsapain]

I have never seen this.

I guess then it does not exist. I have never seen an armadillo but they do exist.

 

[jwk]

Not really convinced that the post-extubation laryngospasm was caused by rapid administration of sugammadex. Anyone with adequate/complete neuromuscular blockade reversal could generate enough negative inspiratory force to cause NPPE.

Lots of other possible causes: extubation during “stage 2” (if it exists), secretions/mucous, inadequate deflation of the ETT balloon, poor extubation technique, airway reactivity, etc.

Sugammadex is a good drug, IMO, and probably superior to neo/glyco based on current data. That being said, agreed overall that it’s not an excuse to be less vigilant or critical of its limitations. Same with any other drug.

Amen brother. This is either laryngospasm, airway obstruction from the tongue, or both. Absolutely nothing to do with suggamadex.

 

[DocMcCoy]

There is, rapid reversal of paralysis resulting in rapidly increasing respiratory force. I am sure you have seen negative pressure pulmonary edema in large athletes / bodybuilder with tube in place which is the most common scenario.

can you explain the mechanism with a patent ETT in place? I'm not following.

 

[GassYous]

There is, rapid reversal of paralysis resulting in rapidly increasing respiratory force. I am sure you have seen negative pressure pulmonary edema in large athletes / bodybuilder with tube in place which is the most common scenario.

Pretty sure it is easier to bring in air from the machine than it is to bring in water from the vasculature

 

[Beeftenderloin]

There is, rapid reversal of paralysis resulting in rapidly increasing respiratory force. I am sure you have seen negative pressure pulmonary edema in large athletes / bodybuilder with tube in place which is the most common scenario.

Yes, but this only happens if they are biting on the tube. Negative pressure pulmonary edema results from negative inspiratory efforts made against a non-patent airway. If the airway is patent, it cannot be negative pressure pulmonary edema, full stop. And if the airway is not patent (ie biting the tube), it’s not suggammadex’s fault, it’s the anesthesiologist’s fault for not putting a bite block in.

 

[vector2]

For the love of god, people, it's S-U-G-A-M-M-A-D-E-X.


Also, it's spelled tuohy

 

[Dr. Rude]

For the love of god, people, it's S-U-G-A-M-M-A-D-E-X.


Also, it's spelled tuohy

Thank you v-i-c-t-o-r-2

 

[DocMcCoy]

For the love of god, people, it's S-U-G-A-M-M-A-D-E-X.


Also, it's spelled tuohy

 

[deleted875186]

For the love of god, people, it's S-U-G-A-M-M-A-D-E-X.


Also, it's spelled tuohy

That’s what we said … sughamidex

 

[2Fast2Des]

You mean sugar-gammadex? Bring on the sugaa!

 

[pgg]

There is, rapid reversal of paralysis resulting in rapidly increasing respiratory force. I am sure you have seen negative pressure pulmonary edema in large athletes / bodybuilder with tube in place which is the most common scenario.

Yes, if they bite the tube and occlude it, which is why an appropriate bite block is important in these people.

That has nothing to do with "rapid reversal" and "rapidly increasing respiratory force" and nothing to do with sugammadex.

 

[UscGhost]

I thought it was sugardicks

 

[nimbus]

What I see is that many providers now get away from using a twitch monitor which is still an important tool even with Suggamadex as it dictates dosing and timing. Suggamadex is not a solution to be less vigilant, I have seen CRNAs (and MDs) give it like water without really thinking...

Yes. We all latch onto the recommendation to use sugammadex preferentially but mostly ignore the other recommendation to use quantitative NMB monitoring at the adductor pollicis. Anyone familiar with the Twitchview EMG monitor? It seems more practical than AMG.

 

[abolt18]

Yes. We all latch onto the recommendation to use sugammadex preferentially but mostly ignore the other recommendation to use quantitative NMB monitoring at the adductor pollicis. Anyone familiar with the Twitchview EMG monitor? It seems more practical than AMG.

We have it. Good for tucked arms, no doubt. I've found it at times to be unreliable.

 

[epidural man]

We have it. Good for tucked arms, no doubt. I've found it at times to be unreliable.

I’d like to use it.

Unreliable at times is EVERY monitor we use. I found the PulseOx to be unreliable at times.

 

[DocVapor]

Unreliable at times is EVERY monitor we use. I found the PulseOx to be unreliable at times.

Funny, that's what the CRNA tells me every time I walk in the room and the sats are in the 70's.

(just making a joke, not commenting on you)

 

[deleted1147063]

Funny, that's what the CRNA tells me every time I walk in the room and the sats are in the 70's.

(just making a joke, not commenting on you)

My "favorite" memory is a similar situation in GI suite, with the CRNA reassuring me: don't trust the monitor, the patient is fine, look he's moving all over the place. My answer: so do people who are drowning (confirmed sat of 60% with my portable Nonin pulse ox).

 

[epidural man]

My "favorite" memory is a similar situation in GI suite, with the CRNA reassuring me: don't trust the monitor, the patient is fine, look he's moving all over the place. My answer: so do people who are drowning (confirmed sat of 60% with my portable Nonin pulse ox).

Why we take on the responsibility of other trained, independent thinking adults is very sad (I was going to type it is shocking…but I guess it isn’t. Greed and laziness in humans is not shocking.)

I am not saying that anyone who supervises is greedy and lazy.

I’m saying that the overall push to want to continue the model comes from a place of greed.

 

[coffeebythelake]

I guess then it does not exist. I have never seen an armadillo but they do exist.

Sugammadex reverses muscle relaxant. It doesn't give the patient super physiologic strength. You establish no mechanism or even a logical rationale for your explanation.

Methinks a patient with NPPE after sugammadex administration is due to the actual mechanism behind NPPE which is breathing against a closed glottis (e.g. larynogspasm) or biting down on the ETT

Edit: pgg beat me to it

 

[thinkorswim]

Yes. We all latch onto the recommendation to use sugammadex preferentially but mostly ignore the other recommendation to use quantitative NMB monitoring at the adductor pollicis. Anyone familiar with the Twitchview EMG monitor? It seems more practical than AMG.

I like using the surgeon as my twitch monitor. It’s cheaper than any alternative and doesn’t require batteries.

 

[MirrorTodd]

I like using the surgeon as my twitch monitor. It’s cheaper than any alternative and doesn’t require batteries.

Tell that to my wife!

 

[pgg]

Yes. We all latch onto the recommendation to use sugammadex preferentially but mostly ignore the other recommendation to use quantitative NMB monitoring at the adductor pollicis. Anyone familiar with the Twitchview EMG monitor? It seems more practical than AMG.

I'll say it.

Quantitative twitch monitoring is next to useless. It's a quirky, user-unfriendly solution in search of a problem.

 

[coffeebythelake]

I'll say it.

Quantitative twitch monitoring is next to useless. It's a quirky, user-unfriendly solution in search of a problem.

I think quantitative monitoring would have been great years ago when we were using neo/glyco
Nowadays with sugammadex there isn't really a need.

 

[epidural man]

I think quantitative monitoring would have been great years ago when we were using neo/glyco
Nowadays with sugammadex there isn't really a need.

The real value of quant monitoring is it can tell you when NOT to use suggaammaddexx.

I would think beam counters trying to dictate practice would make sure every station had quant monitoring and enforce use.

 

[Iso4ane]

interesting thing about livers is that since roc is largely metabolized by the liver, it will lead to prolonged paralysis from your initial bolus until the new one is perfused... which is when you want the paralytic to be eliminated.... works out quite nicely.

Yeah, I always use Roc for livers. New liver will take care of it, and if it doesn’t you’ll be having bigger problems than residual Roc flying around.

 

[Maz777]

I guess then it does not exist. I have never seen an armadillo but they do exist.

I'm not sure you understand the pathophysiology of NPPE. You're going to be hard pressed to find anyone that will agree with you. It's like saying that double-strength espressos contribute to car crashes because a handful of people had those in the car with them at the time of the accident. Rapid reversal of neuromuscular blockade does not contribute to NPPE. The lack of a patent airway does.

 

[lotsapain]

I'm not sure you understand the pathophysiology of NPPE. You're going to be hard pressed to find anyone that will agree with you. It's like saying that double-strength espressos contribute to car crashes because a handful of people had those in the car with them at the time of the accident. Rapid reversal of neuromuscular blockade does not contribute to NPPE. The lack of a patent airway does.

Thank you I always wanted to be educated by a millennial couple of years out of residency who thinks a world of himself. Work a bit longer then educate me on the intricacies of airway management.

 

[lotsapain]

I'll say it.

Quantitative twitch monitoring is next to useless. It's a quirky, user-unfriendly solution in search of a problem.

Did you guys read any books, or Suggamadex labels? do you not understand the pharmacology of the drug or its dosing? For the especially bright:

https://www.merckconnect.com/static/pdf/bridion-sugammadex-dosing-considerations.pdf

You need to measure twitches to dose appropriately aside from the obvious that is from the insert. Underdose and see what happens. If you dose everyone at supramaximal doses... go back to CRNA school

 

[The Duck Knows]

Did you guys read any books, or Suggamadex labels? do you not understand the pharmacology of the drug or its dosing? For the especially bright:

https://www.merckconnect.com/static/pdf/bridion-sugammadex-dosing-considerations.pdf

You need to measure twitches to dose appropriately aside from the obvious that is from the insert. Underdose and see what happens. If you dose everyone at supramaximal doses... go back to CRNA school

I don’t recall guidelines specifically for quantitative TOF, just qualitative TOF, no?

I agree with PGG that the quantitative accelerometry it more trouble than it’s worth for routine use. The number of cases with tucked arms alone means that you won’t be able to get a good exam until the drapes are down. Not to mention how few hospitals are willing to buy them and keep track of them.

 

[pgg]

Did you guys read any books, or Suggamadex labels? do you not understand the pharmacology of the drug or its dosing? For the especially bright:

https://www.merckconnect.com/static/pdf/bridion-sugammadex-dosing-considerations.pdf

You need to measure twitches to dose appropriately aside from the obvious that is from the insert. Underdose and see what happens. If you dose everyone at supramaximal doses... go back to CRNA school

Bah

You clearly have no idea what causes NPPE if you think it has anything to do with the speed of or dose of reversal agents, as you stated earlier.

We've discussed sugammadex dosing quite a few times here, and we're all well aware of the manufacturer recommendations, and that the studies were done with weight based dosing.

Unless you're grossly overdosing your neuromuscular blocking drugs, and a patient has a twitch or even a posttetanic twitch, a simple unit dose 200 mg vial is Just Fine for 99% of patients. Giving someone 200 mg, even if the manufacturer-recommended 2 mg/kg works out to 157.37 mg, isn't a problem.

You're either overthinking it, or underthinking it. I can't tell which. You're definitely obnoxious about your dogma, though.

 

[coffeebythelake]

Thank you I always wanted to be educated by a millennial couple of years out of residency who thinks a world of himself. Work a bit longer then educate me on the intricacies of airway management.

The hostility here is astounding. Don't try to appeal to your great experience and knowledge, and don't try to make this an issue of old vs young. This is about right vs wrong. You do realize that your previous explanation was wrong... !!

 

[vector2]

Did you guys read any books, or Suggamadex labels?

Lol, did you?

 

[UscGhost]

Did you guys read any books, or Suggamadex labels? do you not understand the pharmacology of the drug or its dosing? For the especially bright:

https://www.merckconnect.com/static/pdf/bridion-sugammadex-dosing-considerations.pdf

You need to measure twitches to dose appropriately aside from the obvious that is from the insert. Underdose and see what happens. If you dose everyone at supramaximal doses... go back to CRNA school

Yup.

And after using it, I quickly realized that they would love you to crack open that second vial to give a 210mg dose when a 190mg works equally well.

The label isn't always accurate or reflective of appropriate clinical use. After all, we have been using Marcaine for spinals for decades despite the label saying "not for spinal anesthesia"