Sugammadex now recommended per ASA

[nimbus]

Lol, did you?

I would need loupes to read that label.

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[MirrorTodd]

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.

OMG dude with arrogance like that, how did you NOT become a surgeon?

 

[coffeebythelake]

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

And you realize that the instructions and dosing recommendations by the manufacturer are "dumbed down" and don't reflect the molecular effects of sugammadex and its high binding affinity to rocuronium.. our anesthesia department and pharmacy have a modified dosing regimen that actually take this into account

For your education:

sugammadex dosing

Per sugammadex labeling we are told to use 2 mg/kg for 1-2 twitches, 4 mg/kg for 1-2 PTC, and 16 mg/kg for RSI rocuronium reversal. I understand the simplistic nature of this to combine drug dose given and pharmacokinetics/pharmacodynamics, but I can only think how irrelevant this type of dosing...

forums.studentdoctor.net

 

[Southpaw]

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.

I don’t think you personally use the drug very much. A lot of people here do and therefore post as such. Having said that, I’m sure you’ll tell me you use it all day every day. Which would be even more bewildering given what you’ve said so far. I don’t care what the label says or what the drug reps recommend (I listened to them during lunch a few years ago), 200mg is plenty for just about anyone in almost any clinical situation.

You also seem to be confusing laryngospasm and bronchospasm, but now that I’ve said I’m sure I’ll get some overly defensive self righteous reply from you meant to demean me.

I’m beginning to see why you’re in group/hospital leadership.

 

[Maz777]

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.

Classic. Go ahead and find me one person here that agrees with your "opinion." It's simply factually incorrect and shows a lack of understanding of physiology. If you post something that is clearly wrong, you are going to get called out on it. Sorry if that upsets you so much.

 

[Maz777]

I don’t think you personally use the drug very much. A lot of people here do and therefore post as such. Having said that, I’m sure you’ll tell me you use it all day every day. Which would be even more bewildering given what you’ve said so far. I don’t care what the label says or what the drug reps recommend (I listened to them during lunch a few years ago), 200mg is plenty for just about anyone in almost any clinical situation.

You also seem to be confusing laryngospasm and bronchospasm, but now that I’ve said I’m sure I’ll get some overly defensive self righteous reply from you meant to demean me.

I’m beginning to see why you’re in group/hospital leadership.

He or she posted a case report from a garbage pay-to-publish journal that does nothing to prove his or her point. They extubated. The patient seemingly laryngospasmed. They got NPPE.

Yet, it is somehow sugammadex's fault and would have been avoid with "gentler" neostigmine. Inane. Some people have no idea how to interpret literature findings or quality. No where in that case report does it describe this "phenomenon" of sugammadex actually causing too rapid of reversal and leading to NPPE.

 

[Onefellswoop87]

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

Ahhh, the Dunning-Kruger appears strong with this one.

Tell me you don’t understand the difference between a qualitative twitch monitor and a quantitative accelerometer without explicitly telling me that you don’t understand the difference.

I completely agree with that quantitative accelerometer is largely an academic tool. It’s annoying to use, must have a baseline (which is painful), so gotta get it after induction but before paralytic. I’ve seen them get tossed by people who don’t know what they are and think they are disposable like certain ecg wires. Or they grow legs and just get lost.
Long case where I’m redosing paralytic, it’s probably been at most an hour from redose to extubation/emergence so it warrants reversal. Short case and I’m intubating, probably not getting to more than 0.9 height difference, so it needs reversal of paralysis.

 

[narcusprince]

Suggamadex is a great drug. Much better than roc. Don’t need a study to tell me that.
I wonder though about the effects of deep, prolonged neuromuscular blockade. I’ve seen CRNA’s (and some docs) run roc infusions through long 6-8 hour cases just because of the availability of suggamadex. I would think that completely blocking the neuromuscular junction for that long can cause significant muscle weakness and atrophy post-op, causing problems, especially if the patient is elderly and has decreased muscle mass at baseline.

Naw…. Unless in the icu and long infusions.