Glycopyrrolate vs atropine

[Dantrolene FC]

Anesthesia resident here.

In regards to bradycardia, when would you use atropine vs glycopyrrolate and why?

My understanding is glycopyrrolate doesn’t cross BBB so it is generally the preferred agent in the OR for mild bradycardia, especially in the elderly.

What if the patient has severe bradycardia? I’ve had a couple instances when the patient has a sudden and brief run of asystole for about 10 seconds. By the time I grab the epinephrine, the heart rate has recovered to ~30 bpm. In one instance, the patient had an art line and had a normal BP. On the other, they had a BP cuff, so I didn’t know what the BP was at that time. In both cases I gave 0.4 mg of atropine. I chose atropine because it’s in the ACLS algorithm, so presumably it must be better than glycopyrrolate in this scenario. I chose 0.4 mg because that’s what in the vial.

Another question. I’ve heard that low doses of glycopyrrolate can cause bradycardia. Is this true? What about atropine? What dose is preferred?

Final question, if the patient is pregnant and bradycardic, do you choose atropine or glycopyrrolate given the differences in placental transfer? Do you give sugammadex in a pregnant or breastfeeding patient? If not, do you use atropine or glyco to counteract the bradycardia from neostigmine in a pregnant lady?

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[Mehd School]

need HR faster soon: Glyco

need HR faster now: Atropine

Reversing paralytic in pregnant patient: Atropine

 

[anbuitachi]

Anesthesia resident here.

In regards to bradycardia, when would you use atropine vs glycopyrrolate and why?

My understanding is glycopyrrolate doesn’t cross BBB so it is generally the preferred agent in the OR for mild bradycardia, especially in the elderly.

What if the patient has severe bradycardia? I’ve had a couple instances when the patient has a sudden and brief run of asystole for about 10 seconds. By the time I grab the epinephrine, the heart rate has recovered to ~30 bpm. In one instance, the patient had an art line and had a normal BP. On the other, they had a BP cuff, so I didn’t know what the BP was at that time. In both cases I gave 0.4 mg of atropine. I chose atropine because it’s in the ACLS algorithm, so presumably it must be better than glycopyrrolate in this scenario. I chose 0.4 mg because that’s what in the vial.

Another question. I’ve heard that low doses of glycopyrrolate can cause bradycardia. Is this true? What about atropine? What dose is preferred?

Final question, if the patient is pregnant and bradycardic, do you choose atropine or glycopyrrolate given the differences in placental transfer? Do you give sugammadex in a pregnant or breastfeeding patient? If not, do you use atropine or glyco to counteract the bradycardia from neostigmine in a pregnant lady?

what is the algorithm for asystole? is it atropine??

 

[UscGhost]

Atropine works faster

 

[anaesthetic]

I’ve given atropine maybe once or twice in my career thus far and only in true emergencies with nothing else readily available.

What’s the cause of the bradycardia? If it’s insufflation or sternal retraction, the first thing I do is yell at the surgeon (i.e., eliminate the cause), especially if it’s severe bradycardia/brief asystole. Patients usually recover from this fairly quickly as you’ve probably noticed, which gives you time to give glyco or diminish the response on repeat insults. On cardiac cases, I’ll usually have epi available, so it’s a non-issue but even then, I’ve rarely had to bump up the HR for hemodynamically insignificant bradycardia.

Atropine isn’t the wrong answer per se. It’s just not the most correct answer most of the time, IMO.

 

[coffeebythelake]

what is the algorithm for asystole? is it atropine??

the algorithm for asystole is epinephrine
atropine has been removed from ACLS for use in PEA or asystole

 

[POW16]

the algorithm for asystole is epinephrine
atropine has been removed from ACLS for use in PEA or asystole

I hope he was joking 🤣

 

[coffeebythelake]

Anesthesia resident here.

In regards to bradycardia, when would you use atropine vs glycopyrrolate and why?

My understanding is glycopyrrolate doesn’t cross BBB so it is generally the preferred agent in the OR for mild bradycardia, especially in the elderly.

What if the patient has severe bradycardia? I’ve had a couple instances when the patient has a sudden and brief run of asystole for about 10 seconds. By the time I grab the epinephrine, the heart rate has recovered to ~30 bpm. In one instance, the patient had an art line and had a normal BP. On the other, they had a BP cuff, so I didn’t know what the BP was at that time. In both cases I gave 0.4 mg of atropine. I chose atropine because it’s in the ACLS algorithm, so presumably it must be better than glycopyrrolate in this scenario. I chose 0.4 mg because that’s what in the vial.

Another question. I’ve heard that low doses of glycopyrrolate can cause bradycardia. Is this true? What about atropine? What dose is preferred?

Final question, if the patient is pregnant and bradycardic, do you choose atropine or glycopyrrolate given the differences in placental transfer? Do you give sugammadex in a pregnant or breastfeeding patient? If not, do you use atropine or glyco to counteract the bradycardia from neostigmine in a pregnant lady?

1. Low dose atropine can cause paradoxical bradycardia. We are talking about less than 0.1 mg

2. For pregnant woman we use neostigmine and atropine because of the glycopyrrolate does not pass the placental barrier and theoretically can lead to fetal bradycardia. Sugammadex is not recommended in pregnant woman due to theoretical effect on blocking progesterone, same reason why women taking hormonal contraceptives told to use alternative means of contraception for 7 days.

3. Why would your vial of atropine only have 0.4 mg? AcLS guidelines for symptomatic bradycardia is now 1 mg IVP not 0.5 mg IVP

4. Whatever drug u use is based on thr patients clinical situation and how rapidly progressive the hemodynamic change is. Glycopyrrolate is slower onset. Atropine is fast. Epinephrine is always a good go to if you are worried about bradycardia and low CO, given in small doses of 15 to 50 mcg IVP, but it won't stick around as long as glyco

 

[anbuitachi]

atropine has always been disappointing to me . i prefer epinephrine. one of my favorite meds

 

[deleted875186]

What cases did you have asystole or that severe of a response.

Maybe other people can comment, but if I think someone is high risk to have a vagal response, I usually pre treat with some glyco, I know it hasn’t been proven to be helpful, but I figure starting at a higher HR is typically helpful.

 

[GassYous]

If you use atropine 1 the heart rate will go to like 120. That's why I only use 0.5 at a time.

 

[leggo_my_ecmo]

3. Why would your vial of atropine only have 0.4 mg? AcLS guidelines for symptomatic bradycardia is now 1 mg IVP not 0.5 mg IVP

Atropine frequently comes in 1ml vials, 0.4mg/ml. The code sticks though are always 1mg/10ml.

 

[epidural man]

What cases did you have asystole or that severe of a response.

Maybe other people can comment, but if I think someone is high risk to have a vagal response, I usually pre treat with some glyco, I know it hasn’t been proven to be helpful, but I figure starting at a higher HR is typically helpful.

Weird things happen under anesthesia.

 

[GassYous]

I always give preop glyco for ects for bradycardia prophylaxis

 

[coffeebythelake]

If you use atropine 1 the heart rate will go to like 120. That's why I only use 0.5 at a time.

When I use atropine it will probably be in a peri arrest situation. So while I agree with you that 0.5 mg atropine will probably produce less tachycardia the HR effect is a little less of a concern when the alternative is bradycardia approaching asystole. Last time I used it was a patient with severe hypoxemia whose heart rate rapidly dropped from 80 to low 40s and was continuing to fall.

 

[GassYous]

When I use atropine it will probably be in a peri arrest situation. So while I agree with you that 0.5 mg atropine will probably produce less tachycardia the HR effect is a little less of a concern when the alternative is bradycardia approaching asystole. Last time I used it was a patient with severe hypoxemia whose heart rate rapidly dropped from 80 to low 40s and was continuing to fall.

The last two times I used it the patient's heart rate dropped to the low 20s and I still only used 0.5 because using more is unnecessary. One was in a colonoscopy and the other was when the GS was pulling on really stuck on adhesions. Both did fine.

 

[abolt18]

atropine has always been disappointing to me . i prefer epinephrine. one of my favorite meds

I agree, except when a patient is on propranolol, then you can get a paradoxical bradycardia (like after a big phenylephrine dose).

 

[anesthesiadoc]

When I trained, it was “Glycopyrrolate when annoyed, Atropine when scared.”
Closely consider the risk:benefit of potential overshoot resulting in tachycardia vs not rapidly resolving the bradycardia. I have a much lower threshold to go straight to atropine for infants and small children.

 

[sanityonleave]

I'm surprised that folks here are using atropine for "scary" / hemodynamically unstable bradycardia...

Maybe I'm just spoiled, but our pharmacy makes 10mcg/mL epi sticks and those are amazing for basically everything. I'd reach for epi every time over atropine for unstable brady. Why give a drug that only raises the HR (sometimes) when you can raise HR, inotropy and SVR? Also atropine lasts forever, which is rarely what I want.

Mild bradycardia > glyco
Severe/"scary" bradycardia > have surgeon stop whatever it is they're doing (pulling on the brainstem during SOC is a favorite), epi, more epi, pacing pads, pacing wires

I don't think I've given atropine in the last 5 years (except NMB reversal in pregnant patients mentioned above)

 

[DocVapor]

I'm surprised that folks here are using atropine for "scary" / hemodynamically unstable bradycardia...

Maybe I'm just spoiled, but our pharmacy makes 10mcg/mL epi sticks and those are amazing for basically everything. I'd reach for epi every time over atropine for unstable brady. Why give a drug that only raises the HR (sometimes) when you can raise HR, inotropy and SVR? Also atropine lasts forever, which is rarely what I want.

Mild bradycardia > glyco
Severe/"scary" bradycardia > have surgeon stop whatever it is they're doing (pulling on the brainstem during SOC is a favorite), epi, more epi, pacing pads, pacing wires

I don't think I've given atropine in the last 5 years (except NMB reversal in pregnant patients mentioned above)

Yeah, you're spoiled. Everywhere I've worked has only stocked 1mg/ml vials of epi. Double diluting isn't hard but it does take longer than just drawing up some atropine and slamming it in. And outside of cardiac cases or CV cripples for non-cardiac surgery I think the risks of tachycardia from atropine are overblown.

 

[periopdoc]

As others have said, a lot of this depends on the clinical situation that brought about the bradycardia, and the severity.

Peritoneal or pleural stretch reflex? Glyco.

Desflurane/ fentanyl induced? Glyco.

Bradycardia after intrathecal? Straight to epi. Easy enough to quickly mix up 10 mcg/ml.

I've had a couple of cases of repeat dose glyco resistant brady, that subsequently had a brisk reaponse to 0.4 of atropine.

I always have esmolol available if the patient is at risk for intolerance of tachycardia.

I wouldn't use sugamadex in a pregnant patient unless it was a true, can't ventilate scenario. Even then I would use the minimum effective dose (200 at a time), and work with MFM to administer exogenous progesterone after the fact.

 

[periopdoc]

Yeah, you're spoiled. Everywhere I've worked has only stocked 1mg/ml vials of epi. Double diluting isn't hard but it does take longer than just drawing up some atropine and slamming it in. And outside of cardiac cases or CV cripples for non-cardiac surgery I think the risks of tachycardia from atropine are overblown.

No need to double dilute. Just do it like you are mixing a stick of Neo. Add 0.1 mL of the concentrated stuff to 9.9 mL of diluent.

 

[deleted875186]

As others have said, a lot of this depends on the clinical situation that brought about the bradycardia, and the severity.

Peritoneal or pleural stretch reflex? Glyco.

Desflurane/ fentanyl induced? Glyco.

Bradycardia after intrathecal? Straight to epi. Easy enough to quickly mix up 10 mcg/ml.

I've had a couple of cases of repeat dose glyco resistant brady, that subsequently had a brisk reaponse to 0.4 of atropine.

I always have esmolol available if the patient is at risk for intolerance of tachycardia.

I wouldn't use sugamadex in a pregnant patient unless it was a true, can't ventilate scenario. Even then I would use the minimum effective dose (200 at a time), and work with MFM to administer exogenous progesterone after the fact.

Is there something new about suga I don’t know. The hormonal changes is all theoretical.

 

[GassYous]

Is there something new about suga I don’t know. The hormonal changes is all theoretical.

I just tell women that it might affect the efficacy of their birth control pills. I don't know that there has been any demonstrated harm to pregnancy.

 

[coffeebythelake]

Is there something new about suga I don’t know. The hormonal changes is all theoretical.

it is theoretical, yes, and there was a recent statement from ACOG and ASA recommending avoidance of sugammadex in pregnant women

 

[periopdoc]

It's probably bull****. I would likely get sued if I administered it and she miscarried for unrelated reasons.

 

[hsb09]

I'm surprised that folks here are using atropine for "scary" / hemodynamically unstable bradycardia...

Maybe I'm just spoiled, but our pharmacy makes 10mcg/mL epi sticks and those are amazing for basically everything. I'd reach for epi every time over atropine for unstable brady. Why give a drug that only raises the HR (sometimes) when you can raise HR, inotropy and SVR? Also atropine lasts forever, which is rarely what I want.

Mild bradycardia > glyco
Severe/"scary" bradycardia > have surgeon stop whatever it is they're doing (pulling on the brainstem during SOC is a favorite), epi, more epi, pacing pads, pacing wires

I don't think I've given atropine in the last 5 years (except NMB reversal in pregnant patients mentioned above)

Yes, it is nice when you have pre-made syringes of Epi at 10 mcg/ml. In cases of profound bradycardia, if there is no pre-made syringe of Epi at 10 mcg/ml, time is of the essence and most reach for the Atropine.

 

[deleted875186]

Yes, it is nice when you have pre-made syringes of Epi at 10 mcg/ml. In cases of profound bradycardia, if there is no pre-made syringe of Epi at 10 mcg/ml, time is of the essence and most reach for the Atropine.

If needed I will open the code epinephrine syringe and inject around 1/4 mL for an approximate 25 mcg dose. Most of the time trying to dilute it takes too much time. Patients with low EF or that I al otherwise concerned about I will dilute an epi syringe before the case.

 

[nimbus]

If needed I will open the code epinephrine syringe and inject around 1/4 mL for an approximate 25 mcg dose. Most of the time trying to dilute it takes too much time. Patients with low EF or that I al otherwise concerned about I will dilute an epi syringe before the case.

I draw out 1ml (100mcg) of the code epi into a 10ml syringe, attach the syringe to the IV clave, dilute to 10ml with LR or whatever is running in the IV and give 1-2ml (10-20mcg). It is not as quick as a prefilled syringe but just as quick as any med drawn out of a vial. I also have a 10mcg/ml epi syringe prepared in advance for high risk patients.

 

[anaesthetic]

If needed I will open the code epinephrine syringe and inject around 1/4 mL for an approximate 25 mcg dose. Most of the time trying to dilute it takes too much time. Patients with low EF or that I al otherwise concerned about I will dilute an epi syringe before the case.

I draw out 1ml (100mcg) of the code epi into a 10ml syringe, attach the syringe to the IV clave, dilute to 10ml with LR or whatever is running in the IV and give 1-2ml (10-20mcg). It is not as quick as a prefilled syringe but just as quick as any med drawn out of a vial. I also have a 10mcg/ml epi syringe prepared in advance for high risk patients.

We had a patient with true anaphylaxis to antibiotics, and it didn’t take me more than 30 seconds to squirt the 1 mg/1 ml epi into a 100 ml bag and draw that up into a 10 ml syringe (took longer for the CRNA to recognize it was anaphylaxis). We ended up giving a couple of sticks from that bag before hemodynamics stabilized.

Obviously as anesthesiologists, we’re probably more vigilant about med dilution than SRNAs, CRNAs, or residents, but I think trying to draw up partial doses of concentrated meds can introduce error in an urgent/emergent situation.

 

[periopdoc]

Obviously as anesthesiologists, we’re probably more vigilant about med dilution than SRNAs, CRNAs, or residents, but I think trying to draw up partial doses of concentrated meds can introduce error in an urgent/emergent situation.

Probably depends on the anesthesiologist too. The guy who has all his drugs drawn up before the patient enters the room, including his "emergency stick of sux?" Yeah, that guy probably needs to be careful about diluting in an emergency.

Those of us who regularly get a patient from OR door to secured airway in under five minutes without pre-drawing anything? Not such a big concern. I still prefer to draw up my induction drugs, and prepare my airway device, in advance, but it doesn't actually save me any time.