If using sugammadex, do you check twitches?

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Do you check twitches if using sugammadex?

  • Yes, looking for 4/4 on ToF

    Votes: 12 12.6%

  • Yes, looking for 2/4 on ToF

    Votes: 13 13.7%

  • Yes, but only need post-tetanic twitches.

    Votes: 18 18.9%

  • No, but want some respiratory effort on PSV

    Votes: 22 23.2%

  • No

    Votes: 30 31.6%
  • Total voters
    95
  • Poll closed .
on a related note , 2 mg/kg ( or one vial maximum) seems to always be enough for full reversal, even with 0/4 twitches. it may take a few minutes but it ends up working. I’ve never had to give 4 mg/kg, and definitely not 16 mg/kg.
 
Depends. If Ive been feeding them Roc the whole case for a fastidious surgeon that cant tolerate any diaphragm movement then I check.

If its been a while then I don't usually check, especially if its a pt of 70kg and that 200mg vial is gonna be like 3mg/kg. Or if its a fatass 150kg person then I may give them 2 vials = 400mg and again dont worry that I need exactly 2 twitches per the recs.

Some people check for 4/4 after dosing… That will tell you nothing useful unless you have quantitative monitoring.
 
We have qualitative NMT immediately available in nearly every OR. Almost zero excuse not to use it. I don't like your answer choices though...
 
For those who don't check twitches at all (and consequently have no idea qt all the depth of neuromuscular blockade)... this is the exact kind of laziness I predicted will happen when sugammadex became mainstream used.
 
JoelJoel84 said:
on a related note , 2 mg/kg ( or one vial maximum) seems to always be enough for full reversal, even with 0/4 twitches. it may take a few minutes but it ends up working. I’ve never had to give 4 mg/kg, and definitely not 16 mg/kg.
Click to expand...

I agree there can be a disconnect between number of twitches and amount needed for reversal. Instead of what you suggest, "2 mg/kg always enough for full reversal", I think it is perhaps more appropriate to think about the molecular interactions of sugammadex and rocuronium. We know binding affinity is extremely high and we know there is 1:1 ratio binding. You can easily calculate the amount of sugammadex needed to bind a given mg dose of rocuronium.
 
I've only had one patient be weak after sugammadex. Used 100 of roc on a big patient and the one hour case ended up being less than fifteen minutes. Suga 200. Pulled ok tidal volumes and seemed ok on dropoff in pacu but I saw him after seeing my next patient with sats in the low 90s and he told me he was having trouble breathing. So I gave him another bottle and he said it was much better.
 
GassYous said:
I've only had one patient be weak after sugammadex. Used 100 of roc on a big patient and the one hour case ended up being less than fifteen minutes. Suga 200. Pulled ok tidal volumes and seemed ok on dropoff in pacu but I saw him after seeing my next patient with sats in the low 90s and he told me he was having trouble breathing. So I gave him another bottle and he said it was much better.
Click to expand...
Dangerous on so many levels
 
NICMAN said:
Always.

I think it is negligence to not check twitches after using Roc. How long does it take? 10 seconds to get a facial twitch at the minimum? Lazy, lazy, lazy.
Click to expand...
As I understand in 200 mg of suggamadex will completely bind to 50 mg of roc in vitro. So if you use that ratio to reverse you should be more than fine. FWIW I rarely checked twitches before suggamadex. Just knowing how much roc was given combined with clinical appearance of the patient is much better than a twitch monitor.
 
dannyboy1 said:
As I understand in 200 mg of suggamadex will completely bind to 50 mg of roc in vitro. So if you use that ratio to reverse you should be more than fine. FWIW I rarely checked twitches before suggamadex. Just knowing how much roc was given combined with clinical appearance of the patient is much better than a twitch monitor.
Click to expand...


3.57 mg sugammadex will bind 1 mg rocuronium. Because of high binding affinity there is essentially no dissociation from suggamadex encapsulation and it creates a strong gradient that pulls rocuronium away from the neuromuscular junction to the plasma.

So yes, you can reverse 50 mg rocuronium with 200 sugammadex even if patient has no post tetanic twitches at case end (e.g. patients with myasthenia gravis, etc)

I still use a twitch monitor though. (Still looking for a good one that shows TOF ratios, any suggestions?) It is standard of care.
 
Last edited:
Obviously you should, because sugammadex dosing is based on twitches. But in reality almost everyone doesn't. I've coached all of my junior residents that not only should you check twitches before and after reversal but you should always chart 4/4 twitches prior to leaving the room. And they should actually have 4/4 twitches...
 
Mehd School said:
Obviously you should, because sugammadex dosing is based on twitches. But in reality almost everyone doesn't. I've coached all of my junior residents that not only should you check twitches before and after reversal but you should always chart 4/4 twitches prior to leaving the room. And they should actually have 4/4 twitches...
Click to expand...
lol that's mildly important. 😉
 
Mehd School said:
Obviously you should, because sugammadex dosing is based on twitches. But in reality almost everyone doesn't. I've coached all of my junior residents that not only should you check twitches before and after reversal but you should always chart 4/4 twitches prior to leaving the room. And they should actually have 4/4 twitches...
Click to expand...

I would argue that should be the case before extubation occurs. 😂😂
 
Assuming I gave a normalish bolus and maintenance dose to a normalish pt I don't check twitches.
 
coffeebythelake said:
3.57 mg sugammadex will bind 1 mg rocuronium. Because of high binding affinity there is essentially no dissociation from suggamadex encapsulation and it creates a strong gradient that pulls rocuronium away from the neuromuscular junction to the plasma.
Click to expand...
That suggests one 200 mg vial for a 50 mg dose, which of course we all recognize as about right. It's interesting to me that we all know how sugammadex works, and yet the package insert advises weight-based dosing.

Why does a 150 kg person who got 50 mg of rocuronium need more sugammadex than a 75 kg person who got 50 mg? I'd argue that they absolutely don't. I did argue that, at an M&M a few months back (not my case being presented 😉) and the room consensus was that weight-based dosing was more correct. Because that's what the package insert said.

Is it maybe because the people who wrote the package insert are assuming we all give 0.6 mg/kg of rocuronium to someone, and therefore a 150 kg person always gets twice the roc dose as a 75 kg person?

That sounds like the kind of arithmetic logic a chemist or pharmacist who's never anesthetized an actual patient would have.



I don't always check twitches if the patient is making respiratory efforts already, or if I didn't give more rocuronium after the induction dose. 200 mg for everyone.
 
Define "check" twitches...

Because if they have a working diaphragm - that absolutely puts you in the 2mg/kg realm. So what will a twitch monitor tell you that you now know for certain? If you don't have quantitative monitoring, you likely need to reverse. You aren't going to give 4mg/kg because they are VERY LIKELY to have at least a single twitch. So what else do you need to know? How does it help you to know if you have 1 twitch, two twitches, or 4? The dose is the same. If you aren't going to reverse regardless (long time has passed since the last dose) - you don't need to know twitches either.

The REASON to use quantitative monitoring (if available) is to tell you if you can get away with not reversing. If they have >90% TOF ratio - no reversal needed. I love using quant monitoring for this reason. Unfortunately, they break at an unbelievable rate - so keeping them around is difficult.

My point is - checking for diaphragm function IS a twitch monitor. It is low fidelity, but gives you all the info you need in the realm of suggamdex usage.
 
pgg said:
That suggests one 200 mg vial for a 50 mg dose, which of course we all recognize as about right. It's interesting to me that we all know how sugammadex works, and yet the package insert advises weight-based dosing.

Why does a 150 kg person who got 50 mg of rocuronium need more sugammadex than a 75 kg person who got 50 mg? I'd argue that they absolutely don't. I did argue that, at an M&M a few months back (not my case being presented 😉) and the room consensus was that weight-based dosing was more correct. Because that's what the package insert said.

Is it maybe because the people who wrote the package insert are assuming we all give 0.6 mg/kg of rocuronium to someone, and therefore a 150 kg person always gets twice the roc dose as a 75 kg person?

That sounds like the kind of arithmetic logic a chemist or pharmacist who's never anesthetized an actual patient would have.



I don't always check twitches if the patient is making respiratory efforts already, or if I didn't give more rocuronium after the induction dose. 200 mg for everyone.
Click to expand...
I suspect you are right about why they suggest a dose of mg/kg - because they assume WE also dosed for mg/kg.

Although volume of distribution may have something to do with it. Just because it binds in a ratio - doesn't mean the drug actually finds it way to the motor endplate easily.

Question - if the vial came in 50mg vial, would you still dose at 200mg - or is this a function of an open vial, you paid the cost - might as well use it all?
 
epidural man said:
I suspect you are right about why they suggest a dose of mg/kg - because they assume WE also dosed for mg/kg.

Although volume of distribution may have something to do with it. Just because it binds in a ratio - doesn't mean the drug actually finds it way to the motor endplate easily.

Question - if the vial came in 50mg vial, would you still dose at 200mg - or is this a function of an open vial, you paid the cost - might as well use it all?
Click to expand...
For 50mg of roc I'd still give 200 even if I had to open more vials. Just like I give a full reversal dose of neostigmine now if the pt got a cumulative full dose of roc pretty much at any point in the last ~4 hrs. The only way I wouldn't is if I had access to quantitative twitch monitoring, which I haven't had since residency.
 
epidural man said:
I suspect you are right about why they suggest a dose of mg/kg - because they assume WE also dosed for mg/kg.

Although volume of distribution may have something to do with it. Just because it binds in a ratio - doesn't mean the drug actually finds it way to the motor endplate easily.

Question - if the vial came in 50mg vial, would you still dose at 200mg - or is this a function of an open vial, you paid the cost - might as well use it all?
Click to expand...
The higher doses are mainly just to hasten onset. The package insert does explicitly acknowledge that the 16 mg/kg dose to reverse an RSI dose of roc is that high in order to ensure reversal happens within 3 minutes.

I hear you about big people and volume of distribution, but sugammadex has such freakishly high affinity for rocuronium that I think the main effect there might just be slower onset. Sooner or later, and generally much sooner than later, the sugammadex finds the rocuronium molecules.

If it came in 50 mg vials I imagine that the recommended 2 mg/kg dose plus time and experience would've taught me that 3 or 4 was the right amount to use.
 
epidural man said:
Define "check" twitches...

Because if they have a working diaphragm - that absolutely puts you in the 2mg/kg realm. So what will a twitch monitor tell you that you now know for certain? If you don't have quantitative monitoring, you likely need to reverse. You aren't going to give 4mg/kg because they are VERY LIKELY to have at least a single twitch. So what else do you need to know? How does it help you to know if you have 1 twitch, two twitches, or 4? The dose is the same. If you aren't going to reverse regardless (long time has passed since the last dose) - you don't need to know twitches either.

The REASON to use quantitative monitoring (if available) is to tell you if you can get away with not reversing. If they have >90% TOF ratio - no reversal needed. I love using quant monitoring for this reason. Unfortunately, they break at an unbelievable rate - so keeping them around is difficult.

My point is - checking for diaphragm function IS a twitch monitor. It is low fidelity, but gives you all the info you need in the realm of suggamdex usage.
Click to expand...

You can have diaphragm function return in the form of currare clefts with zero twitches and barely post tetanics. It js quite resistant to effects of neuromuscular blockade so jt is usually last to go and first to recover.
 
epidural man said:
I suspect you are right about why they suggest a dose of mg/kg - because they assume WE also dosed for mg/kg.

Although volume of distribution may have something to do with it. Just because it binds in a ratio - doesn't mean the drug actually finds it way to the motor endplate easily.

Question - if the vial came in 50mg vial, would you still dose at 200mg - or is this a function of an open vial, you paid the cost - might as well use it all?
Click to expand...
Sugammadex doesn't travel to the motor endplate. It remains in the plasma and acts as a sink to the rocuronium molecules in the bloodstream. Gobbles them all up and pulls the roc from the rest of the body back into the plasma.
 
As an aside I'm at a hospital that still gets upset if you use sugammadex routinely for financial reasons.

If we had quant ulnar TOF ratios, I wouldn't mind using neo/glyco on obese, COPD patients, those with high abd incisions, etc.

Until they do I'll continue to use it. Ironically the VA, which has quant TOF, also has sugammadex flowing like water 😂
 
coffeebythelake said:
You can have diaphragm function return in the form of currare clefts with zero twitches and barely post tetanics. It js quite resistant to effects of neuromuscular blockade so jt is usually last to go and first to recover.
Click to expand...
I would argue that currare cleft is not return of function.
 
coffeebythelake said:
I still use a twitch monitor though. (Still looking for a good one that shows TOF ratios, any suggestions?) It is standard of care.
Click to expand...
We got the StimPod in every OR at my residency hospital at the end of my CA-2 year and it's great. Shows you TOF ratios and you can use it even with arms tucked (just have to remember to put it on before circulators go ham with positioning). It's fun to check twitches after giving sugammadex and watch the ratio go from something like 0.2 to 0.9 in about 1 minute.
 
coffeebythelake said:
For those who don't check twitches at all (and consequently have no idea qt all the depth of neuromuscular blockade)... this is the exact kind of laziness I predicted will happen when sugammadex became mainstream used.
Click to expand...
Also consider that it doesn't really matter, because sugammadex is very very good.
 
pgg said:
That suggests one 200 mg vial for a 50 mg dose, which of course we all recognize as about right. It's interesting to me that we all know how sugammadex works, and yet the package insert advises weight-based dosing.

Why does a 150 kg person who got 50 mg of rocuronium need more sugammadex than a 75 kg person who got 50 mg? I'd argue that they absolutely don't. I did argue that, at an M&M a few months back (not my case being presented 😉) and the room consensus was that weight-based dosing was more correct. Because that's what the package insert said.

Is it maybe because the people who wrote the package insert are assuming we all give 0.6 mg/kg of rocuronium to someone, and therefore a 150 kg person always gets twice the roc dose as a 75 kg person?

That sounds like the kind of arithmetic logic a chemist or pharmacist who's never anesthetized an actual patient would have.



I don't always check twitches if the patient is making respiratory efforts already, or if I didn't give more rocuronium after the induction dose. 200 mg for everyone.
Click to expand...
I do not always check twitches my logic is if they can Trigger the vent on psv with a 3l flow trigger then they likely have 4/4 twitches and 2mg/kg is enough. Now dont get me started on those who give 157mg versus 200mg or those who give 340mg versus 400mg. My thoughts are you give one amp or two. Sometimes we are our own biggest enemies.
 
narcusprince said:
I do not always check twitches my logic is if they can Trigger the vent on psv with a 3l flow trigger then they likely have 4/4 twitches and 2mg/kg is enough. Now dont get me started on those who give 157mg versus 200mg or those who give 340mg versus 400mg. My thoughts are you give one amp or two. Sometimes we are our own biggest enemies.
Click to expand...

Same, that's also how I do it with labetalol and epi.
 
I've administered two bottles exactly once;
80kg, 65 y.,ASA3 patient on the fit and healthy side that got a spontaneous 91% 4/4 TOF return of muscular function, triggered the PSV with the flow trigger limit at 2l/min,25 minutes after 50mg of rocuronium.

Redosed 25mg at the start of surgery,hoping it'd give me 20 more minutes, but no. 10 minutes into the lap chole, start receiving complaints about contractions. Rechecking TOF, three minutes after exactly zero response, TOF at 3/4. Visually verified. Redosed 25,called my attending to let him know what's up, got the go ahead to just administer whatever needed to keep TOF below 2, and went on with the case.

90 minutes later, an uneventful, not shockingly (for our place) long surgery, I'd ended up administering 200mg of rocuronium, 150 of which during surgery. 20 minutes after the last dose, I got, of course 0/4 twitches, called my attending who just said to give two bottles of sugammadex. Zero to 100% 4/4,exactly one minute.

The GA was a TCI prop and remi. About 320mg/h of the former, 300mcg/h of the latter at the time of the first spontaneous respiratory effort.

Next pt: ASA2, bmi of 35 as the only booster, lasted a good hour with his induction dose of 50mg (0.45mg/kg true weight dosage). He got,like most of our choles, exactly zero sugammadex, as he was TOF 4/4 with PSV triggered at closure.
 
norski said:
I've administered two bottles exactly once;
80kg, 65 y.,ASA3 patient on the fit and healthy side that got a spontaneous 91% 4/4 TOF return of muscular function, triggered the PSV with the flow trigger limit at 2l/min,25 minutes after 50mg of rocuronium.

Redosed 25mg at the start of surgery,hoping it'd give me 20 more minutes, but no. 10 minutes into the lap chole, start receiving complaints about contractions. Rechecking TOF, three minutes after exactly zero response, TOF at 3/4. Visually verified. Redosed 25,called my attending to let him know what's up, got the go ahead to just administer whatever needed to keep TOF below 2, and went on with the case.

90 minutes later, an uneventful, not shockingly (for our place) long surgery, I'd ended up administering 200mg of rocuronium, 150 of which during surgery. 20 minutes after the last dose, I got, of course 0/4 twitches, called my attending who just said to give two bottles of sugammadex. Zero to 100% 4/4,exactly one minute.

The GA was a TCI prop and remi. About 320mg/h of the former, 300mcg/h of the latter at the time of the first spontaneous respiratory effort.

Next pt: ASA2, bmi of 35 as the only booster, lasted a good hour with his induction dose of 50mg (0.45mg/kg true weight dosage). He got,like most of our choles, exactly zero sugammadex, as he was TOF 4/4 with PSV triggered at closure.
Click to expand...

Why do they need zero twitches for a lap chole

Why run remi when you are paralyzing

Why would you not reverse

Wtf are they teaching you
 
coffeebythelake said:
Sugammadex is great, nobody is saying otherwise. But dosing matters.
Click to expand...
Depending on your acuity and patient population, the vast majority (like 90%+) of pts get a standard induction dose of roc followed by standard maintenance doses. Unless you had to give a whole bunch more NMB late in the case for whatever reason and you suspect the pt has a dense 0 twitch block, the dosing really doesn't matter (give 1 vial and you're good).

And just anecdotally, in 2+ yrs of almost exclusive sug use and little twitch monitoring, I've only had to redose it once in the PACU. And that includes anesthetics with vecuronium.
 
vector2 said:
Depending on your acuity and patient population, the vast majority (like 90%+) of pts get a standard induction dose of roc followed by standard maintenance doses. Unless you had to give a whole bunch more NMB late in the case for whatever reason and you suspect the pt has a dense 0 twitch block, the dosing really doesn't matter (give 1 vial and you're good).

And just anecdotally, in 2+ yrs of almost exclusive sug use and little twitch monitoring, I've only had to redose it once in the PACU. And that includes anesthetics with vecuronium.
Click to expand...

This is starting to sound like one of those arguments like "I never wear a seat belt and I'm still OK". I would have hoped for a better response for ignoring standard of care.
 
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