C’mon, ASA

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Luckily, I’ve only had one complaint about myalgias with sux. She was pretty unhappy. I usually give the “defasciculating” dose of Roc, but this was a special case. She had an LMA in, and was hiccuping. I’ve found that 10-20 mg of sux will stop the hiccups (I’ve often wondered if it could be tried for persistent/intractable hiccups, kinda like doing an ECT, give a dose of induction agent, then the sux, and bag/mask for 5 minutes until they get back to spontaneous respiration).

Anyway, it made quick work of her hiccups on the LMA, she did well, otherwise, but she complained on the nursing follow up that her “whole body hurt”. Myalgias…
 
Keep in mind that unless you’re calling the patient a day or two after the case to see if they have myalgias, you’ll never know it happened.

It’s like when you lift weights for the first time in a while- you don’t feel that sore right after, it’s the next day that gets you. Same thing.
 
anbuitachi said:
people that against sux? i use sux most of the time on folks. just prop sux tube. works great. patients wake up and go home happy
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Myalgias
Not that useful when roc + sugamma is much more versatile (long cases, short cases, medium cases)
Then the rare case of pseudo cholinesterase def

Not really much reason to use sux if you have sugammadex available
 
DirtDocMD said:
Luckily, I’ve only had one complaint about myalgias with sux. She was pretty unhappy. I usually give the “defasciculating” dose of Roc, but this was a special case. She had an LMA in, and was hiccuping. I’ve found that 10-20 mg of sux will stop the hiccups (I’ve often wondered if it could be tried for persistent/intractable hiccups, kinda like doing an ECT, give a dose of induction agent, then the sux, and bag/mask for 5 minutes until they get back to spontaneous respiration).

Anyway, it made quick work of her hiccups on the LMA, she did well, otherwise, but she complained on the nursing follow up that her “whole body hurt”. Myalgias…
Click to expand...

Just stick a q tip in her nose next timw
 
DirtDocMD said:
Luckily, I’ve only had one complaint about myalgias with sux. She was pretty unhappy. I usually give the “defasciculating” dose of Roc, but this was a special case. She had an LMA in, and was hiccuping. I’ve found that 10-20 mg of sux will stop the hiccups (I’ve often wondered if it could be tried for persistent/intractable hiccups, kinda like doing an ECT, give a dose of induction agent, then the sux, and bag/mask for 5 minutes until they get back to spontaneous respiration).

Anyway, it made quick work of her hiccups on the LMA, she did well, otherwise, but she complained on the nursing follow up that her “whole body hurt”. Myalgias…
Click to expand...


20-30mg of roc also does the trick.
 
I am old enough to have used curare back in the day. 3 mg of curare was extremely reliable in blocking fasiculations from sux and occasional blurry vision pre induction was the only common complaint. 1 mg of vecuronium is pretty good. Once we evolved to propofol and rocuronium it is very rare I use sux.
 
There are graduating residents these days that have never used sux. It is appalling.
 
Maz777 said:
There are graduating residents these days that have never used sux. It is appalling.
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One of our new grads has never used Neostigmine / Glyco for reversal. Like, ever.

Was taught Sugammadex is standard of care now, and he’s probably right. (Notwithstanding female contraception issues).
 
Drwine said:
I am old enough to have used curare back in the day. 3 mg of curare was extremely reliable in blocking fasiculations from sux and occasional blurry vision pre induction was the only common complaint. 1 mg of vecuronium is pretty good. Once we evolved to propofol and rocuronium it is very rare I use sux.
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Any non depolarizer given in the right dose and enough time before sux will block fasciculations from sux. Curare just had the most literature on it. 3mg (1ml) for all before Sux was the most common pregame cocktail. Also everyone loved the thought of giving arrow poison to patients. 🙂
 
JoelJoel84 said:
One of our new grads has never used Neostigmine / Glyco for reversal. Like, ever.

Was taught Sugammadex is standard of care now, and he’s probably right. (Notwithstanding female contraception issues).
Click to expand...

Remember, do NOT create new standards of care. They only hurt us. What if you go to a place that doesn’t have sugammadex? What if you go to a place that has it, but you have to request it to be sent to you? Standards of care only help lawyers against us.
 
JoelJoel84 said:
One of our new grads has never used Neostigmine / Glyco for reversal. Like, ever.

Was taught Sugammadex is standard of care now, and he’s probably right. (Notwithstanding female contraception issues).
Click to expand...
Sad. Most residents these days don't even check twitches during cases. Taught to just blindly give a vial or two of sugammadex and all will be fine.
 
DirtDocMD said:
Luckily, I’ve only had one complaint about myalgias with sux. She was pretty unhappy. I usually give the “defasciculating” dose of Roc, but this was a special case. She had an LMA in, and was hiccuping. I’ve found that 10-20 mg of sux will stop the hiccups (I’ve often wondered if it could be tried for persistent/intractable hiccups, kinda like doing an ECT, give a dose of induction agent, then the sux, and bag/mask for 5 minutes until they get back to spontaneous respiration).

Anyway, it made quick work of her hiccups on the LMA, she did well, otherwise, but she complained on the nursing follow up that her “whole body hurt”. Myalgias…
Click to expand...
Lower dose of sux appears to increase myalgias
 
centdoc said:
Remember, do NOT create new standards of care. They only hurt us. What if you go to a place that doesn’t have sugammadex? What if you go to a place that has it, but you have to request it to be sent to you? Standards of care only help lawyers against us.
Click to expand...
True

However I am thankful for Sugammadex. I got tired of dealing with pacu patients who didnt get appropriate doses of glyco/neostig and were clearly suffering from residual paralysis.

It was always an issue with the older anesthesiologists.

Once sugammadex came along, it was no longer an issue

While yes it's good to be familiar with alternative agents. It's also hard to find a justification for using glyco/neo anymore
 
Giving defasciculating doses of roc before using succ makes no sense.

The entire point of using succ is that it provides the best intubating conditions faster than anything else. I hate the drug, but when you want the best conditions ASAP there's no substitute - not even high dose roc is as good. I'll use succ for RSIs or for really fat people who I know are going to desaturate quickly even after careful preoxygenating, but never for anything else.

Defasciculating doses delay the onset of succ by blocking the receptors. You're literally ruining the one redeeming quality that drug has.

What's more, a defasciculating dose doesn't even reliably prevent the myalgias.

It's a bizarre practice and people should stop doing it. 🙂
 
pgg said:
Giving defasciculating doses of roc before using succ makes no sense.

The entire point of using succ is that it provides the best intubating conditions faster than anything else. I hate the drug, but when you want the best conditions ASAP there's no substitute - not even high dose roc is as good. I'll use succ for RSIs or for really fat people who I know are going to desaturate quickly even after careful preoxygenating, but never for anything else.

Defasciculating doses delay the onset of succ by blocking the receptors. You're literally ruining the one redeeming quality that drug has.

What's more, a defasciculating dose doesn't even reliably prevent the myalgias.

It's a bizarre practice and people should stop doing it. 🙂
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I use sux maybe 5-6 times a year in exactly the same manner, for the true RSIs I’m worried about. Never understood defasciculating dose of roc, and would never use it on these patients.
 
UscGhost said:
Myalgias
Not that useful when roc + sugamma is much more versatile (long cases, short cases, medium cases)
Then the rare case of pseudo cholinesterase def

Not really much reason to use sux if you have sugammadex available
Click to expand...
I’m in Florida. The roc is defective half the time. I don’t now how long they leave it in the warehouse in the Florida heat but it doesn’t work half the time when it’s suppose to work in a couple of minute.

Roc used to be stored in refrigerator back in the old days when we still use bullards and light wands. And im convicnce the Florida heat degrades roc

Roc should be refrigerated between 36-46 degrees f or 2-8 degree c


I think sux is more resistant to the Florida heat in the warehouse or wherever it’s stored.
 
aneftp said:
I’m in Florida. The roc is defective half the time. I don’t now how long they leave it in the warehouse in the Florida heat but it doesn’t work half the time when it’s suppose to work in a couple of minute.

Roc used to be stored in refrigerator back in the old days when we still use bullards and light wands. And im convicnce the Florida heat degrades roc

Roc should be refrigerated between 36-46 degrees f or 2-8 degree c


I think sux is more resistant to the Florida heat in the warehouse or wherever it’s stored.
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Well that's Florida for ya. Lots of defective stuff down there
 
Non refrigerated roc is definitely less effective.

I use succinylcholine for the quick cases that need a tube but don’t need paralysis or can’t have paralysis (ercps/nerve monitoring). Spray their trachea with lido or bupi if it’s a long spine. For the quick cases I usually did this out of stewardship for pharmacy costs…however getting more cynical and just roc and a lot of sugammadex doesn’t seem so bad.

Defasiculating dose is not bizarre…it’s just rarely needed. In a healthy muscular person undergoing surgery where they can’t be paralyzed (I was at a big trauma center, young healthy people with spine trauma) I use it. I’m sure most experienced people on here have seen the muscular dudes who fasiculate …those people usually don’t report it but if you’ve had to follow up on it they did not like the myalgias, and why not prevent it? Give a little suggamadex after to keep neuromonitoring happy
 
DirtDocMD said:
Luckily, I’ve only had one complaint about myalgias with sux. She was pretty unhappy. I usually give the “defasciculating” dose of Roc, but this was a special case. She had an LMA in, and was hiccuping. I’ve found that 10-20 mg of sux will stop the hiccups (I’ve often wondered if it could be tried for persistent/intractable hiccups, kinda like doing an ECT, give a dose of induction agent, then the sux, and bag/mask for 5 minutes until they get back to spontaneous respiration).

Anyway, it made quick work of her hiccups on the LMA, she did well, otherwise, but she complained on the nursing follow up that her “whole body hurt”. Myal
Click to expand...
GassYous said:
Just stick a q tip in her nose next timw
Click to expand...
This guy knows…can also do a small ng
 
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