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FlacoFlo

I have recently read and spoken with some of my attendings about this new drug coming down the pipeline (currently in Phase III trials under my understanding). I was just wondering what other residents have been hearing about this at their institutions?? Has anyone had the chance to use it?? I have just noticed the flurry of research published in A & A about it. Let me know what you think/heard?? Because according to Ron Miller, its the next best thing in Anesthesia since ether!!
 

Gasboy07

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I think the way that we had hoped sugammadex could be used is to replace suxamethonium as the choice of agent for RSI. I've read one study (can't remember where, but one of the major journals anesthesiology / BJA) is that it took 3 minutes to reverse from deep relaxation from TOF ratio 0.9. Trouble is I can't remember where is started from.

There is a study in a recent issue of anesthesiology comparing reversal of vec and roc from T2, and this was done in around 1.5 minutes using 3 - 4mg/kg of sugammedex.

Sounds good - but the one situation where it won't save you is the can't intubate can't ventilate patient, because by the time you wait (60 seconds), have a look, fiddle around a bit and decide that maybe we should get the sugammedex now while waiting for it to work it's probably around 10 minutes, too late to save the patient.

Limits your choice of relaxant though.
 

Mman

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In my limited experience, the stuff works like a charm. I had one patient go from nowhere near having a twitch to fully reversed in about 2.5 minutes.

As for the problem of timing, if it's in the drug cart in the room you can draw it up and give it right away regardless of how much Roc you just pushed if the need arises.

I can't imagine how expensive the stuff is going to be, but it will certainly have it's uses.
 
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Gasboy07

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That's the thing I really want to know - can you - give 0.9mg/kg of Roc (or more!) then go oh ****... then grab the sugammadex and have the patient go from nothing to breathing all before he desats... and can it do it reliably?

I must find that study again...
 

dhb

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That's the thing I really want to know - can you - give 0.9mg/kg of Roc (or more!) then go oh ****... then grab the sugammadex and have the patient go from nothing to breathing all before he desats... and can it do it reliably?

I must find that study again...

Yes,
from what i've heard you can use it after any amount of roc and reverse in 3 min
 

apellous

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We have it at one of our hospitals. I myself have not used it, but many other residents have used it. They are says the same things, 0/4 TOF >>> full reversal 2 min. It will replace sux for RSI if it turns out not to have the side effects/contraindications of sux. Not sure if it can be used IM like sux can in emergency, but will mostly replace sux.
 

Mman

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That's the thing I really want to know - can you - give 0.9mg/kg of Roc (or more!) then go oh ****... then grab the sugammadex and have the patient go from nothing to breathing all before he desats... and can it do it reliably?

I must find that study again...


Supposedly, you can. I think there is a formula for the dose of it you need to give based on the dose of Rocuronium given, but you can reverse from any point if you give enough. It's also basically a sugar molecule and pretty low side effect profile.

I haven't used it enough to remember the dosing and when I have used it, it was as part of some studies and a study coordinator was telling me what dose to give.
 

Gasboy07

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I can't imagine too many people using...sux routinely - One of my bosses said to me regarding sux "always have it, never use it". Not strictly possibly but wirth remembering.
 

Gasboy07

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I think I didn't express myself clearly - there are specific indications for using sux which I'm sure I don't need to discuss. The post that suggested people only use sux for suspected difficult intubations seem to suggest something different.

Can you think of any situation where you'd still use sux instead of Roc / Suggamedex (besides anaphylaxis to roc) if it proves to work as well as advertised (or as others seem to experience?).

It even sounds like you might be able to use Roc at doses we're never previously tried to bring time to intubating conditions down to somewhere near sux for RSI.

For someone who might be difficult to ventilate - you could do the same.

For short procedures, even better as you can have an on off switch.

Sux has so many side effects I think we're still using it because we have nothing better (or didn't kill patients ala rapacurium)
 

Intubate

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If cost were not an issue, I guess I can't think of an instance in which sux would be preferable to roc/suggamadex (provided it lives up to the billing that it is perfect in every way and completely infallible), with the exception of known allergy to either.

The other issue is routine use of Sux. I use it everyday for routine cases, and would venture to say that many people do.
 

Bougie

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On a tangent, anyone know why mivacurium was discontinued? It seems like a great short acting nondepolarizer if sux is contraindicated or pt has bad kidneys/liver. Maybe a little histamine release. My attendings said that it never really made a niche which I thought was odd. I guess sugammadex will put an end to pursuing a short acting nondepolizer.
 

Gasboy07

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You can still get it in Oz... so I don't know. Maybe people weren't using it enough as if you can get away with mivacurium half dose atrac is just as good and you can reverse it more reliably?
 

Planktonmd

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On a tangent, anyone know why mivacurium was discontinued? It seems like a great short acting nondepolarizer if sux is contraindicated or pt has bad kidneys/liver. Maybe a little histamine release. My attendings said that it never really made a niche which I thought was odd. I guess sugammadex will put an end to pursuing a short acting nondepolizer.

Mivacurium was a little better than saline as a muscle relaxant.
It was discontinued because it was not making money.
 

dhb

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We still have mivacurium in Europe and use it it didn't replace sux because although it's short acting it' takes 3+min to be able to intubate
 

zippa

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Today's WSJ : http://blogs.wsj.com/health/2008/08/01/safety-first-fda-rejects-schering-plough-anesthesia-reverser/

FDA Rejects Schering-Plough Anesthesia Reverser

In a surprise, the FDA has rejected Schering-Plough’s application to sell a drug called sugammadex, the company said. Even in today’s tough safety climate, the thumbs-down is unusual because it goes against the unanimous recommendation of outside experts to the agency that it approve the drug, the first of its kind.

Crazyness! It seemed like a done deal.
 

lord_jeebus

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Today's WSJ : http://blogs.wsj.com/health/2008/08/01/safety-first-fda-rejects-schering-plough-anesthesia-reverser/

FDA Rejects Schering-Plough Anesthesia Reverser

In a surprise, the FDA has rejected Schering-Plough’s application to sell a drug called sugammadex, the company said. Even in today’s tough safety climate, the thumbs-down is unusual because it goes against the unanimous recommendation of outside experts to the agency that it approve the drug, the first of its kind.

Strange, it just got approved in Europe too...
 
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