If using sugammadex, do you check twitches?

[dannyboy1]

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The laziness that suggamadex breeds is not so much the not checking twitches. Before, you actually had to have a reasonable plan for wake-up (can’t have them too paralyzed, or you won’t be able to reverse but can’t have them jumping around during closure). Now you can just run a dense block till the drapes come down.

 

[norski]

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

1: I certainly don't. Our "home" surgeons bitch and moan about complete paralysis, to the degree that our attendings
gave up and just let them have their way. Our surgeons are also not quick. I won't say bad, but slow. They did, at some point, learn about NMT monitoring, and demand to see TOF ratio if applicable to any difficulties.

2: saves on propofol or other drugs. Tubes hurt for the first few whiles, and as remi is quicker to titrate to negate any noceous stimuli from the tube than prop, it gets used. While I realize that a similar result could be achieved with magnesium, lido or beta blockers, we're running remi either way for induction and surgery, so a couple of mls (100-150mcg while waiting for the surgeons to get ready) doesn't matter in the long haul. Also cheap and easy, so why not. I do realize we're in completely different practice climates,though. Standard of practice here is likely different from your place. We're trained, by senior nurse anesthetists, but mostly by anesthesiologists, to anticipate and treat stimuli with opioids (remi, fent or alfentanil). Residents are mostly, as far as I know, trained likewise in the use of remi.

Not saying that when we run a TCI TIVA, only two or three drugs are involved, but we're not really trained with iv lidocaine, and the only iv beta blocker available is metoprolol. I think you might have esmolol? While rapid in effect, I find that metoprolol iv doesn't do much to alleviate increases in heart rate for any longer than remi does.

So, why not low flow sevo or des with analgesic, opioid or non so, adjuncts instead of prop and remi? Environmentalists are onto them. We don't even have nitrous! Also, PACU nurses hate us when we bring them sevo breath patients.

3: I'd not reverse if there's nothing to actually reverse. 4 twitches at a previously calibrated (pre nmb) 100% and spontaneous breathing means to me that the effect has taken its course. I could, of course, administer neostigmine, but we only get that in a mix with glycopyrrulate, in a 2.5/0.5mg a ml mix, so all that would buy my patient is an hour's worth of tachycardia,maybe some salivation and nausea. Sugammadex, to myself, my attendings and my colleague nurse anesthetists, at that point, is pretty useless.

Sorry if I'm upsetting anyone,and especially towards Gassyous, snarky crna behavior isn't intentional. I just realized that there seems to be some sort of discourse between Scandinavian and American practice of anesthesia, so the lengthy reply can partly be blamed on my need to explain. The other blame can be shifted to four 24/7 calls in a row, then three IPAs tonight.

English is not my first language, so anything you may read between the lines probably isn't there. Norwegians tend to be pretty easy reading. I've been on these boards for a few years, really enjoy reading and once in a while participating in discussions, and absolutely see that a nurse in a physician's forum isn't the most popular thing in the world. If I were ten years younger, the road to MD and becoming an anesthesiologist would be in the cards, but I'm just too old to make that a socially and fiscally viable project! So, with that outlook, I just enjoy whichever knowledge or viewpoint is shared. Thank you!

 

[Mman]

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.

there is ample evidence from Neostigmine that anesthesiologists (and everyone else) are not able to clinically recognize small degrees of residual NM blockade postoperatively.

 

[Mman]

Now you can just run a dense block till the drapes come down.

please do not tell surgeons this

 

[coffeebythelake]

1: I certainly don't. Our "home" surgeons bitch and moan about complete paralysis, to the degree that our attendings
gave up and just let them have their way. Our surgeons are also not quick. I won't say bad, but slow. They did, at some point, learn about NMT monitoring, and demand to see TOF ratio if applicable to any difficulties.

Sounds like q common theme everywhere

2: saves on propofol or other drugs. Tubes hurt for the first few whiles, and as remi is quicker to titrate to negate any noceous stimuli from the tube than prop, it gets used. While I realize that a similar result could be achieved with magnesium, lido or beta blockers, we're running remi either way for induction and surgery, so a couple of mls (100-150mcg while waiting for the surgeons to get ready) doesn't matter in the long haul. Also cheap and easy, so why not. I do realize we're in completely different practice climates,though. Standard of practice here is likely different from your place. We're trained, by senior nurse anesthetists, but mostly by anesthesiologists, to anticipate and treat stimuli with opioids (remi, fent or alfentanil). Residents are mostly, as far as I know, trained likewise in the use of remi.

Seems like you guys use remifentanil a LOT at your institution. It's an expensive drug. We use it sparingly and for specific reasons (e.g., tiva with motor monitoring, contraindications for NMBDs, as plan for smooth wakeup, etc)

3: I'd not reverse if there's nothing to actually reverse. 4 twitches at a previously calibrated (pre nmb) 100% and spontaneous breathing means to me that the effect has taken its course. I could, of course, administer neostigmine, but we only get that in a mix with glycopyrrulate, in a 2.5/0.5mg a ml mix, so all that would buy my patient is an hour's worth of tachycardia,maybe some salivation and nausea. Sugammadex, to myself, my attendings and my colleague nurse anesthetists, at that point, is pretty useless.

If you have quantitative TOF >0.9 then you shouldn't need to give reversal agent. Agree

 

[MirrorTodd]

1: I certainly don't. Our "home" surgeons bitch and moan about complete paralysis, to the degree that our attendings
gave up and just let them have their way. Our surgeons are also not quick. I won't say bad, but slow. They did, at some point, learn about NMT monitoring, and demand to see TOF ratio if applicable to any difficulties.

2: saves on propofol or other drugs. Tubes hurt for the first few whiles, and as remi is quicker to titrate to negate any noceous stimuli from the tube than prop, it gets used. While I realize that a similar result could be achieved with magnesium, lido or beta blockers, we're running remi either way for induction and surgery, so a couple of mls (100-150mcg while waiting for the surgeons to get ready) doesn't matter in the long haul. Also cheap and easy, so why not. I do realize we're in completely different practice climates,though. Standard of practice here is likely different from your place. We're trained, by senior nurse anesthetists, but mostly by anesthesiologists, to anticipate and treat stimuli with opioids (remi, fent or alfentanil). Residents are mostly, as far as I know, trained likewise in the use of remi.

Not saying that when we run a TCI TIVA, only two or three drugs are involved, but we're not really trained with iv lidocaine, and the only iv beta blocker available is metoprolol. I think you might have esmolol? While rapid in effect, I find that metoprolol iv doesn't do much to alleviate increases in heart rate for any longer than remi does.

So, why not low flow sevo or des with analgesic, opioid or non so, adjuncts instead of prop and remi? Environmentalists are onto them. We don't even have nitrous! Also, PACU nurses hate us when we bring them sevo breath patients.

3: I'd not reverse if there's nothing to actually reverse. 4 twitches at a previously calibrated (pre nmb) 100% and spontaneous breathing means to me that the effect has taken its course. I could, of course, administer neostigmine, but we only get that in a mix with glycopyrrulate, in a 2.5/0.5mg a ml mix, so all that would buy my patient is an hour's worth of tachycardia,maybe some salivation and nausea. Sugammadex, to myself, my attendings and my colleague nurse anesthetists, at that point, is pretty useless.

Sorry if I'm upsetting anyone,and especially towards Gassyous, snarky crna behavior isn't intentional. I just realized that there seems to be some sort of discourse between Scandinavian and American practice of anesthesia, so the lengthy reply can partly be blamed on my need to explain. The other blame can be shifted to four 24/7 calls in a row, then three IPAs tonight.

English is not my first language, so anything you may read between the lines probably isn't there. Norwegians tend to be pretty easy reading. I've been on these boards for a few years, really enjoy reading and once in a while participating in discussions, and absolutely see that a nurse in a physician's forum isn't the most popular thing in the world. If I were ten years younger, the road to MD and becoming an anesthesiologist would be in the cards, but I'm just too old to make that a socially and fiscally viable project! So, with that outlook, I just enjoy whichever knowledge or viewpoint is shared. Thank you!

If you haven't used this trick yet, you can just push a saline flush and then say "alright how's that?" Occasionally, check twitches again and say out loud "Yep, no twitches."
Obviously, it's better to be honest with your colleagues, but it doesn't really sound like you have the choice given the culture at your institution so **** em.

 

[norski]

Remi is about us$10/2mg in Norway. 500mcg of fentanyl is about us$3, for comparison. How much is remi in the US? We dilute a 2mg glass with saline to 50mcg/ml, and most of the time, we split syringes into halves or quarts for shorter cases.

Sounds like q common theme everywhere



Seems like you guys use remifentanil a LOT at your institution. It's an expensive drug. We use it sparingly and for specific reasons (e.g., tiva with motor monitoring, contraindications for NMBDs, as plan for smooth wakeup, etc)



If you have quantitative TOF >0.9 then you shouldn't need to give reversal agent. Agree

 

[norski]

If you haven't used this trick yet, you can just push a saline flush and then say "alright how's that?" Occasionally, check twitches again and say out loud "Yep, no twitches."
Obviously, it's better to be honest with your colleagues, but it doesn't really sound like you have the choice given the culture at your institution so **** em.

Love the approach! Done that a few times, simultaneously adding a bit of sevo, but a TOF they think about is something they want to see. Disconnecting it from the patient can, of course, work, though. The dynamic, at least with the younger surgeons, is such that I can call them out on their crap, having them take to heart the message, and vice versa, if there's any special wants they might have. Older ones, not so much.

 

[vector2]

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.

there is ample evidence from Neostigmine that anesthesiologists (and everyone else) are not able to clinically recognize small degrees of residual NM blockade postoperatively.

That seatbelt analogy is a total strawman. The risk reduction and benefit:harm ratios are probably an order of magnitude different between the scenarios, given the molecular mechanism and known clinical efficacy of sugammadex. A more apt analogy is that we're trying to confirm ETT placement, we've heard bilateral breath sounds, we have repeating ETCO2....but it's not good enough for you because we didn't drop a bronch and look at tracheal rings. That's the degree of redundancy you're asking for given how crazy efficacious sug is.

Is checking twitches easy? Sure. But assuming your vial of sug is actually a vial of sug, you dosed your roc *appropriately*, and your pt doesn't have renal or liver dysfunction, it's a virtual certainty you are going to get to at least a ~0.9 ratio. So at that point, unless you have quantitative twitch monitoring (which I do not) it's folly to think that your qualitative eyeball assessment of twitch intensity decrement / TOF meant a GD thing (unlike say ETCO2 or bronch which are extremely sensitive and specific).

And of course I think we can probably give some benefit of the doubt to our fellow non-twitch-checking SDN anesthesiologists that they've done some clinical assessment of the pt's strength and aren't just pulling the tube and calling it a day cause they injected 1 vial.

 

[coffeebythelake]

Remi is about us$10/2mg in Norway. 500mcg of fentanyl is about us$3, for comparison. How much is remi in the US? We dilute a 2mg glass with saline to 50mcg/ml, and most of the time, we split syringes into halves or quarts for shorter cases.

Interesting how the prices vary so much. Qt my institution remifentanil is about $30 for 1 mg, and fentanyl is about $1 for 250 mcg.

 

[deleted875186]

1: I certainly don't. Our "home" surgeons bitch and moan about complete paralysis, to the degree that our attendings
gave up and just let them have their way. Our surgeons are also not quick. I won't say bad, but slow. They did, at some point, learn about NMT monitoring, and demand to see TOF ratio if applicable to any difficulties.

2: saves on propofol or other drugs. Tubes hurt for the first few whiles, and as remi is quicker to titrate to negate any noceous stimuli from the tube than prop, it gets used. While I realize that a similar result could be achieved with magnesium, lido or beta blockers, we're running remi either way for induction and surgery, so a couple of mls (100-150mcg while waiting for the surgeons to get ready) doesn't matter in the long haul. Also cheap and easy, so why not. I do realize we're in completely different practice climates,though. Standard of practice here is likely different from your place. We're trained, by senior nurse anesthetists, but mostly by anesthesiologists, to anticipate and treat stimuli with opioids (remi, fent or alfentanil). Residents are mostly, as far as I know, trained likewise in the use of remi.

Not saying that when we run a TCI TIVA, only two or three drugs are involved, but we're not really trained with iv lidocaine, and the only iv beta blocker available is metoprolol. I think you might have esmolol? While rapid in effect, I find that metoprolol iv doesn't do much to alleviate increases in heart rate for any longer than remi does.

So, why not low flow sevo or des with analgesic, opioid or non so, adjuncts instead of prop and remi? Environmentalists are onto them. We don't even have nitrous! Also, PACU nurses hate us when we bring them sevo breath patients.

3: I'd not reverse if there's nothing to actually reverse. 4 twitches at a previously calibrated (pre nmb) 100% and spontaneous breathing means to me that the effect has taken its course. I could, of course, administer neostigmine, but we only get that in a mix with glycopyrrulate, in a 2.5/0.5mg a ml mix, so all that would buy my patient is an hour's worth of tachycardia,maybe some salivation and nausea. Sugammadex, to myself, my attendings and my colleague nurse anesthetists, at that point, is pretty useless.

Sorry if I'm upsetting anyone,and especially towards Gassyous, snarky crna behavior isn't intentional. I just realized that there seems to be some sort of discourse between Scandinavian and American practice of anesthesia, so the lengthy reply can partly be blamed on my need to explain. The other blame can be shifted to four 24/7 calls in a row, then three IPAs tonight.

English is not my first language, so anything you may read between the lines probably isn't there. Norwegians tend to be pretty easy reading. I've been on these boards for a few years, really enjoy reading and once in a while participating in discussions, and absolutely see that a nurse in a physician's forum isn't the most popular thing in the world. If I were ten years younger, the road to MD and becoming an anesthesiologist would be in the cards, but I'm just too old to make that a socially and fiscally viable project! So, with that outlook, I just enjoy whichever knowledge or viewpoint is shared. Thank you!

I also think this anesthetic is wack. Nothing wrong if that’s what you want to do, but I typically TIVA for specific reasons, mostly PONV. Low flow sevo is fairly environmentally friendly, and definitely more cost effective, it’s 100% easier, and it potentiates the muscle relaxation.

Prop, lido, roc, tube, sevo low flow, hydromorphone for wake up. Less work, more predictable anesthetic, patient will wake up fast.

Who cares about “sevo breath” complaints from the PACU.

 

[jwk]

Seems like you guys use remifentanil a LOT at your institution. It's an expensive drug. We use it sparingly and for specific reasons (e.g., tiva with motor monitoring, contraindications for NMBDs, as plan for smooth wakeup, etc)

Most folks in my hospitals think remi is pretty much a garbage drug with very limited indications. It's mainly the newer guys that think it's something amazing when it really isn't a big deal at all. I think routine use of remi is largely inappropriate.

 

[jwk]

1: I certainly don't. Our "home" surgeons bitch and moan about complete paralysis, to the degree that our attendings
gave up and just let them have their way. Our surgeons are also not quick. I won't say bad, but slow. They did, at some point, learn about NMT monitoring, and demand to see TOF ratio if applicable to any difficulties.

Wimpy. 😉

I've seen a number of quantitative block monitors over many years. I have yet to see one that provides any better evidence or is more useful than a simple hand-held nerve stimulator.

Remember that "anesthesia makes surgery possible not easy" applies to just about every case you do. (and the hematologic corollary to that is hemostasis is a surgical problem - we didn't make the incision).

 

[deleted875186]

For what it’s worth, I do keep 0-2 twitches at the corrugator muscle for lap cases, I think even if the surgeon doesn’t complain, it’s probably best fir the patient. Some papers showing less postoperative pain with deep neuromuscular block compared to lighter block during lap surgery.

 

[hiyaman]

Wimpy. 😉

I've seen a number of quantitative block monitors over many years. I have yet to see one that provides any better evidence or is more useful than a simple hand-held nerve stimulator.

Remember that "anesthesia makes surgery possible not easy" applies to just about every case you do. (and the hematologic corollary to that is hemostasis is a surgical problem - we didn't make the incision).

lol but if patient is ESLD, then hemostasis is also an anesthesia problem. But i get what you are trying to point out.

 

[pgg]

I think routine use of remi is largely inappropriate.

If not harmful. Opioid induced hyperalgesia is a real thing and remi is probably the worst offender.

 

[GassYous]

For what it’s worth, I do keep 0-2 twitches at the corrugator muscle for lap cases, I think even if the surgeon doesn’t complain, it’s probably best fir the patient. Some papers showing less postoperative pain with deep neuromuscular block compared to lighter block during lap surgery.

I want to help my surgeons get their cases done quickly and well but if you keep telling me that the paralysis is not good 2 minutes after 50 of roc it aint the paralysis homeboy

 

[dhb]

Interesting how the prices vary so much. Qt my institution remifentanil is about $30 for 1 mg, and fentanyl is about $1 for 250 mcg.

5 x 1 mg	U.H.			[ 7 € ]
5 x 2 mg	U.H.			[ 15 € ]

 

[fakin' the funk]

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.

My shop exclusively uses sugammadex. Very rare use of cis/neo/glyco. I'm aware in 4 years also of just 1 recurarization after sugammadex, which was clinically obvious in the PACU and came after a long-case total of something like 600mg rocuronium (like 8/kg total dose over 8 hours). It can happen.

 

[fakin' the funk]

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.

This metaphor is bad. So what, you use like a crappy seatbelt and check it constantly?

Invoking the "standard of care" here is silly. And I'm being nice in response to your rudeness here. What happens when the standard of care changes due to a killer app like sugammadex?

 

[fakin' the funk]

please do not tell surgeons this

Paramount. THEY MUST NEVER KNOW

 

[2Fast2Des]

Twitches are for b****es

 

[Burned_Out]

I want to revive this thread because it seems the attitude of why bother checking twitches when a single 200mg sugammadex dose reverses all paralysis is completely idiotic. I had to take care of someone else’s PACU patient tonight who just had ex. lap surgery. The doc did not once bother to monitor twitches during the case even though qualitative twitch monitors (Twitchview & Tetragraph) machines were available. He just gave 200 mg of Sugammadex, extubated and dropped patient off in the PACU. Well, patient got into resp. distress while I was there and we had to mask ventilate until we could check twitches & order more Sugammadex. Doc who did case was not even there.

I see this lazy “why bother to monitor when I’ve got Sugammadex” attitude even among the supposedly more intelligent practitioners. You can see this irresponsible attitude from the responses in this older thread from 2021. It’s just stupid, lazy and irresponsible. People who do this also do not have a deep understanding of paralysis as you would think.

I get deer in the headlight looks when I tell people:
-Sugammadex is not indicated for renal impairment as defined by GFR < 30.
-Some patients are Sugammadex resistant.
-Higher doses of Sugammadex increases risk of anaphylaxis

I get a lot of pushback from these idiots saying I’m making this crap up,

 

[UscGhost]

I want to revive this thread because it seems the attitude of why bother checking twitches when a single 200mg sugammadex dose reverses all paralysis is completely idiotic. I had to take care of someone else’s PACU patient tonight who just had ex. lap surgery. The doc did not once bother to monitor twitches during the case even though qualitative twitch monitors (Twitchview & Tetragraph) machines were available. He just gave 200 mg of Sugammadex, extubated and dropped patient off in the PACU. Well, patient got into resp. distress while I was there and we had to mask ventilate until we could check twitches & order more Sugammadex. Doc who did case was not even there.

I see this lazy “why bother to monitor when I’ve got Sugammadex” attitude even among the supposedly more intelligent practitioners. You can see this irresponsible attitude from the responses in this older thread from 2021. It’s just stupid, lazy and irresponsible. People who do this also do not have a deep understanding of paralysis as you would think.

I get deer in the headlight looks when I tell people:
-Sugammadex is not indicated for renal impairment as defined by GFR < 30.
-Some patients are Sugammadex resistant.
-Higher doses of Sugammadex increases risk of anaphylaxis

I get a lot of pushback from these idiots saying I’m making this crap up,

Well,

Checking twitches and "ordering more sugamma" implies that sug did work. Was it a dosing issue? How much roc was given during the case?

I did a quick google search of sugam resistance. Found a couple case reports that mentioned that neo/glyco was also given..which complicates the picture. What would be the suspected mechanism? I have personally never heard of it.

Sug is used all the time in esrd, renal impairment. Works fine. Issues with it appear to be anecdotal at best and its unclear that glyo/neo plus roc/cis would be free of complications

Sugammadex administration in patients with end-stage renal disease: a narrative review with recommendations - PMC

Due to unknown safety concerns, sugammadex should not be administered to patients with end-stage renal disease (ESRD). However, because the supply of benzylisoquinolinium-type neuromuscular blocking agents (NMBAs) has been discontinued, rocuronium ...

pmc.ncbi.nlm.nih.gov

 

[CopaceticOne]

I want to revive this thread because it seems the attitude of why bother checking twitches when a single 200mg sugammadex dose reverses all paralysis is completely idiotic. I had to take care of someone else’s PACU patient tonight who just had ex. lap surgery. The doc did not once bother to monitor twitches during the case even though qualitative twitch monitors (Twitchview & Tetragraph) machines were available. He just gave 200 mg of Sugammadex, extubated and dropped patient off in the PACU. Well, patient got into resp. distress while I was there and we had to mask ventilate until we could check twitches & order more Sugammadex. Doc who did case was not even there.

I see this lazy “why bother to monitor when I’ve got Sugammadex” attitude even among the supposedly more intelligent practitioners. You can see this irresponsible attitude from the responses in this older thread from 2021. It’s just stupid, lazy and irresponsible. People who do this also do not have a deep understanding of paralysis as you would think.

I get deer in the headlight looks when I tell people:
-Sugammadex is not indicated for renal impairment as defined by GFR < 30.
-Some patients are Sugammadex resistant.
-Higher doses of Sugammadex increases risk of anaphylaxis

I get a lot of pushback from these idiots saying I’m making this crap up,

I’ve seen it under dosed more than anything. Sometimes roc hangs around longer than expected. Or folks forget that some of the bigger patients would need a larger dose.

For PACU issues, critical thinking and reviewing the anesthesia record is my first go to. If the sugammadex dose seems to be on the lower side of the range and there are clinical findings consistent with incomplete reversal, I will empirically give more. Guess what, either it worked or it didn’t.

I don’t know what your work environment is, but I suggest a collegial conversation with the person to just give a heads up about the PACU course.

 

[surgndoc]

The roc-sugammadex complex is cleared much slower in ESRD. So you have to be a little more careful, especially depending on long cases where a large mg dosage of roc has been given.

An hour case with 50mg roc and 200 sugammadex prob fine. A 5 hr case with 200mg roc and 200 mg sugammadex you might run into trouble. And it will be after the pt has been in pacu for awhile.

 

[abolt18]

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...

My how the turn tables. In my current practice, we do not have twitch monitors in every room, and so I virtually never check twitches. Previous place had them in ever room, so we checked everyone.

In my practice, my partners and I are pretty light with paralytic. Rarely redose after induction unless truly needed. 200mg sugammedex is virtually always enough (though the 150kg+ patients will often get more).

 

[Iso4ane]

If you do 200mg only, I feel you have to do one of two options:
1) if you don’t want to check TOF, light on paralytic.
2) if you want to be heavy handed on paralytic, you should check TOF.

You shouldn’t be both heavy handed on paralytic and don’t check TOF.

You can be like on of my colleagues who gives 600mg to everyone (please don’t do that), and the one time you have to reintubate/paralyze them again….

 

[UscGhost]

If you do 200mg only, I feel you have to do one of two options:
1) if you don’t want to check TOF, light on paralytic.
2) if you want to be heavy handed on paralytic, you should check TOF.

You shouldn’t be both heavy handed on paralytic and don’t check TOF.

You can be like on of my colleagues who gives 600mg to everyone (please don’t do that), and the one time you have to reintubate/paralyze them again….

Yup.

200mg of sug should eliminate around 60mg of Roc. Then you can account for time, time since last dose, metabolism, patient size, muscle mass, etc

 

[cittykat]

There is an ASA guideline that says every patient who gets NMB should get quantitative monitoring. That places a lot of practices at medicolegal risk. I brought it up in our own practice. We still have quantitative monitoring in just a couple of rooms.

2023 American Society of Anesthesiologists... : Anesthesiology

These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular...

journals.lww.com

• “This practice guideline provides evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents. The objective is to guide practice that will enhance patient safety by reducing residual neuromuscular blockade. It is recommended to use quantitative neuromuscular monitoring at the adductor pollicis and to confirm a recovery of train-of-four ratio greater than or equal to 0.9 before extubation. Sugammadex is recommended from deep, moderate, and shallow levels of neuromuscular blockade that is induced by rocuronium or vecuronium. Neostigmine is a reasonable alternative from minimal blockade (train-of-four ratio in the range of 0.4 to less than 0.9). Patients with adequate spontaneous recovery to train-of-four ratio greater than or equal to 0.9 can be identified with quantitative monitoring, and these patients do not require pharmacological antagonism.“

 

[coolforschool]

There is a guideline that says every patient who gets nondepolarizing NMB should get quantitative monitoring. That places a lot of practices at medicolegal risk. I brought it up in our own practice. We still don’t have quantitative monitoring.

2023 American Society of Anesthesiologists... : Anesthesiology

These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular...

journals.lww.com

• “This practice guideline provides evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents. The objective is to guide practice that will enhance patient safety by reducing residual neuromuscular blockade. It is recommended to use quantitative neuromuscular monitoring at the adductor pollicis and to confirm a recovery of train-of-four ratio greater than or equal to 0.9 before extubation. Sugammadex is recommended from deep, moderate, and shallow levels of neuromuscular blockade that is induced by rocuronium or vecuronium. Neostigmine is a reasonable alternative from minimal blockade (train-of-four ratio in the range of 0.4 to less than 0.9). Patients with adequate spontaneous recovery to train-of-four ratio greater than or equal to 0.9 can be identified with quantitative monitoring, and these patients do not require pharmacological antagonism.“

We have quantitative monitoring in all of our ORs. Not surprisingly, the devices are somewhat unreliable even with proper use (obtaining baselines before paralytic, application/positioning, unobstructed arm, etc.). It will show 0/4 PTC, and the patient will still buck/cough/breath somehow.

When it works, it works well, but on the whole, they’re pretty unreliable for cases where you actually need paralysis.

 

[Burned_Out]

There is an ASA guideline that says every patient who gets NMB should get quantitative monitoring. That places a lot of practices at medicolegal risk. I brought it up in our own practice. We still have quantitative monitoring in just a couple of rooms.

2023 American Society of Anesthesiologists... : Anesthesiology

These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular...

journals.lww.com

• “This practice guideline provides evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents. The objective is to guide practice that will enhance patient safety by reducing residual neuromuscular blockade. It is recommended to use quantitative neuromuscular monitoring at the adductor pollicis and to confirm a recovery of train-of-four ratio greater than or equal to 0.9 before extubation. Sugammadex is recommended from deep, moderate, and shallow levels of neuromuscular blockade that is induced by rocuronium or vecuronium. Neostigmine is a reasonable alternative from minimal blockade (train-of-four ratio in the range of 0.4 to less than 0.9). Patients with adequate spontaneous recovery to train-of-four ratio greater than or equal to 0.9 can be identified with quantitative monitoring, and these patients do not require pharmacological antagonism.“

I agree. A lot of departments are buying these quantitative monitors because of the ASA guidelines. Just like ignoring NPO guidelines, you deviate from the standard of care at yours & your patients risk.

 

[Burned_Out]

We have quantitative monitoring in all of our ORs. Not surprisingly, the devices are somewhat unreliable even with proper use (obtaining baselines before paralytic, application/positioning, unobstructed arm, etc.). It will show 0/4 PTC, and the patient will still buck/cough/breath somehow.

When it works, it works well, but on the whole, they’re pretty unreliable for cases where you actually need paralysis.

I have my difficulties too with some of these Twitchview or Tetragraph monitors. I find that the sensor adhesive is not maintaining skin contact after repeated stimulation cycles. I address this by wrapping tape over the sensor. Some inattentive people also place the sensor directly over the radial nerve or median-ulnar ligament. I get maybe 1 failure to sense every 20-25 cases. In the event the machine fails, I just break out the old nerve stimulator.

People bring up the reliability issues of the quant. Monitors to excuse themselves from ever needing to check TOF ratios.

 

[coolforschool]

I have my difficulties too with some of these Twitchview or Tetragraph monitors. I find that the sensor adhesive is not maintaining skin contact after repeated stimulation cycles. I address this by wrapping tape over the sensor. Some inattentive people also place the sensor directly over the radial nerve or median-ulnar ligament. I get maybe 1 failure to sense every 20-25 cases. In the event the machine fails, I just break out the old nerve stimulator.

People bring up the reliability issues of the quant. Monitors to excuse themselves from ever needing to check TOF ratios.

Eh. I agree not measuring TOF at all is questionable. I usually check qualitative TOF, reverse with sugammadex, then check for sustained tetany. If they still appear weak post-extubation or in PACU, I give them more. Much more reliable, cheaper, and easier than using the Twitchview/tetragraph which is bulky, has to be plugged in, and has questionable reliability/accuracy. We use the Tetragraph often due to institutional policy, but I have been utterly unimpressed having used it for >1 year now.

 

[coffeebythelake]

This metaphor is bad. So what, you use like a crappy seatbelt and check it constantly?

Invoking the "standard of care" here is silly. And I'm being nice in response to your rudeness here. What happens when the standard of care changes due to a killer app like sugammadex?

No. What I'm saying with the seatbelt analogy is... "never had a problem with it before so that means it must be safe without it"

 

[UscGhost]

There is an ASA guideline that says every patient who gets NMB should get quantitative monitoring. That places a lot of practices at medicolegal risk. I brought it up in our own practice. We still have quantitative monitoring in just a couple of rooms.

2023 American Society of Anesthesiologists... : Anesthesiology

These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular...

journals.lww.com

• “This practice guideline provides evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents. The objective is to guide practice that will enhance patient safety by reducing residual neuromuscular blockade. It is recommended to use quantitative neuromuscular monitoring at the adductor pollicis and to confirm a recovery of train-of-four ratio greater than or equal to 0.9 before extubation. Sugammadex is recommended from deep, moderate, and shallow levels of neuromuscular blockade that is induced by rocuronium or vecuronium. Neostigmine is a reasonable alternative from minimal blockade (train-of-four ratio in the range of 0.4 to less than 0.9). Patients with adequate spontaneous recovery to train-of-four ratio greater than or equal to 0.9 can be identified with quantitative monitoring, and these patients do not require pharmacological antagonism.“

Eh. More data doesnt necessarily mean less medicolegal risk.

Artifacts, incorrect data, lawyers misinterpret the data, mechanical issues. Then a complication happens and they blame the fact that the patient was reintubated in pacu because your TOF monitor happened to come loose and ahow 0/4 twitches...

 

[cittykat]

Eh. More data doesnt necessarily mean less medicolegal risk.

Artifacts, incorrect data, lawyers misinterpret the data, mechanical issues. Then a complication happens and they blame the fact that the patient was reintubated in pacu because your TOF monitor happened to come loose and ahow 0/4 twitches...

If the national specialty society recommends a monitor and you don’t use it in your routine practice, you put yourself at risk. The absence of the monitor would be indefensible and look terrible to a jury.

 

[UscGhost]

If the national specialty society recommends a monitor and you don’t use it in your routine practice, you put yourself at risk. The absence of the monitor would be indefensible and look terrible to a jury.

Only if you dont properly reverse your patient.

The incidence of postop residual paralysis was far higher before sugamma. And that was when using a twitch monitor was far more important. Most dont use it correctly... physicians arent very good at testing and evaluating twitch ratios and tetany and many others just ignored it

Never heard or seen a case of "sugam resistance". I have heard and seen MANY cases of postop residual paralysis from neo/glyco reversals. Never heard of a malpractice case from it.

But if it makes you feel better that people just use to check the box 4/4 twitches...

 

[cittykat]

Only if you dont properly reverse your patient.

The incidence of postop residual paralysis was far higher before sugamma. And that was when using a twitch monitor was far more important. Most dont use it correctly... physicians arent very good at testing and evaluating twitch ratios and tetany and many others just ignored it

Exactly why the ASA recommends quantitative monitoring.

Never heard or seen a case of "sugam resistance". I have heard and seen MANY cases of postop residual paralysis from neo/glyco reversals. Never heard of a malpractice case from it.

Agree with this. Still residual paralysis is not good for patients.

 

[pgg]

There is an ASA guideline that says every patient who gets NMB should get quantitative monitoring. That places a lot of practices at medicolegal risk. I brought it up in our own practice. We still have quantitative monitoring in just a couple of rooms.

2023 American Society of Anesthesiologists... : Anesthesiology

These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular...

journals.lww.com

• “This practice guideline provides evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents. The objective is to guide practice that will enhance patient safety by reducing residual neuromuscular blockade. It is recommended to use quantitative neuromuscular monitoring at the adductor pollicis and to confirm a recovery of train-of-four ratio greater than or equal to 0.9 before extubation. Sugammadex is recommended from deep, moderate, and shallow levels of neuromuscular blockade that is induced by rocuronium or vecuronium. Neostigmine is a reasonable alternative from minimal blockade (train-of-four ratio in the range of 0.4 to less than 0.9). Patients with adequate spontaneous recovery to train-of-four ratio greater than or equal to 0.9 can be identified with quantitative monitoring, and these patients do not require pharmacological antagonism.“

Quantitative monitoring is bull****. They could put one in every room and hire a tuxedo'd butler to apply it to every patient and I still wouldn't use it.

These ASA statements are written by clowns who think you can't use rocuronium to flush the propofol in.

 

[cittykat]

Quantitative monitoring is bull****. They could put one in every room and hire a tuxedo'd butler to apply it to every patient and I still wouldn't use it.

These ASA statements are written by clowns who think you can't use rocuronium to flush the propofol in.

I partly agree. It’s practical only when arms are out which is only a small proportion of our cases. I’m mostly a roc flusher myself.

 

[zizzer]

No, but mostly because our hospital can't seem to keep them in every OR and I don't want to ask for one from the anesthesia techs every day.

 

[pgg]

I partly agree. It’s practical only when arms are out which is only a small proportion of our cases. I’m mostly a roc flusher myself.

I'll go a step further and say it's never practical because you can never trust it enough in the rare (if not ridiculous) cases where you wonder if there's residual blockade but can't quite tell based on a simple qualitative twitch monitor AND for some reason don't want to reverse the patient. And that's assuming the device is present and not broken.

It's a sloppy, inconvenient, annoying, quirky, half-solution looking for a problem. Exactly the sort of angel-dancing pinhead mental masturbation that makes academia and these ASA author goofballs look silly.

I think they suck.

 

[Burned_Out]

Well,

Checking twitches and "ordering more sugamma" implies that sug did work. Was it a dosing issue? How much roc was given during the case? 3-4 vials over 3 hrs.

I did a quick google search of sugam resistance. Found a couple case reports that mentioned that neo/glyco was also given..which complicates the picture. What would be the suspected mechanism? I have personally never heard of it. There’s literature on this subject. Need to find my source. I only brought it up as another reason to check TOF before you extubate. Underdosing sugammadex is the more common reason for incomplete reversal, which could have been detected with TOF monitoring….which this guy did not bother to do.

Sug is used all the time in esrd, renal impairment. Works fine. Issues with it appear to be anecdotal at best and its unclear that glyo/neo plus roc/cis would be free of complications
Sugammadex can wear off faster than the paralytic will in these patients. You need to read the manufacturer’s warning on it…not to use if GFR<30. There have been recurarization reports in esrd with sugammadex. It’s not anecdotal. I will use roc on my esrd patients if cis- is not available. I will reverse with neostig.-glyco. and treat further with Sugammadex if the TOF ratio is not 0.9. Better to have both reversal drugs onboard than just one.

Sugammadex administration in patients with end-stage renal disease: a narrative review with recommendations - PMC

Due to unknown safety concerns, sugammadex should not be administered to patients with end-stage renal disease (ESRD). However, because the supply of benzylisoquinolinium-type neuromuscular blocking agents (NMBAs) has been discontinued, rocuronium ...

pmc.ncbi.nlm.nih.gov

 

[Burned_Out]

I'll go a step further and say it's never practical because you can never trust it enough in the rare (if not ridiculous) cases where you wonder if there's residual blockade but can't quite tell based on a simple qualitative twitch monitor AND for some reason don't want to reverse the patient. And that's assuming the device is present and not broken.

It's a sloppy, inconvenient, annoying, quirky, half-solution looking for a problem. Exactly the sort of angel-dancing pinhead mental masturbation that makes academia and these ASA author goofballs look silly.

I think they suck.

But you still do check TOF with the qualitative monitors at least? Even after sugammadex reversal?

 

[Burned_Out]

Yup.

200mg of sug should eliminate around 60mg of Roc. Then you can account for time, time since last dose, metabolism, patient size, muscle mass, etc

That’s a lot of guessing and extrapolating to convince yourself you don’t need TOF monitoring. I would rather be assured 100% of the time with TOF monitoring than wrong even once with my guessing.

 

[UscGhost]

Of course underdosing will incompletely reverse it. So dont underdose it. Testing just MAY help confirm that you underdosed..which you should know anyway.

Then again, TOF has been around forever..and it didn't prevent incomplete reversal before. So i dont expect it to do so now. Incomplete reversal dropped dramatically once sugamma came around.

Those studies didnt suggest recurarization, just seem to be vague references to some esrd patients needing intubation 48 hrs later...from any number of causes (such as fluid overload)

The articles only say "not enough data". In the end..paralytic and reversal is vastly more reliable in ESRD patients using sugamma than roc plus nep/glyco. So ill go with the safer option..even if its off label

Even using cis..the cis breaks down faster than the neo, so you can have muscle weakness from that too.

 

[UscGhost]

That’s a lot of guessing and extrapolating to convince yourself you don’t need TOF monitoring. I would rather be assured 100% of the time with TOF monitoring than wrong even once with my guessing

That’s a lot of guessing and extrapolating to convince yourself you don’t need TOF monitoring. I would rather be assured 100% of the time with TOF monitoring than wrong even once with my guessing.

Not really. Many studies show that clinicians are terrible at calculating TOF ratios and they dont measure tetany consistently.

Pretty rare to need more than 60-70mg roc for a case.

But hey, feel free to show me studies that show the incidence of documented post op residual muscle paralysis with roc/sug when giving 200mg. I may change my mind. Then again, if people are routinely giving massive 100mg roc doses to intubate a lap appy..i would agree that those folks should use TOF as they are excessively paralyzing.

Also, the incidence of postop resid block in esrd patients using sug vs neo?

Sugammadex Versus Neostigmine for Reversal of Neuromuscular Blockade in Patients With Severe Renal Impairment: A Randomized, Double-Blinded Study - PubMed

In patients with severe renal impairment, neuromuscular blockade with rocuronium followed by reversal with sugammadex provides a significantly faster return of neuromuscular function compared to cisatracurium and neostigmine, without any major adverse effects.

pubmed.ncbi.nlm.nih.gov

Results: The mean time to recovery of TOFR ≥90% was significantly faster with sugammadex at 3.5 (±1.6) min compared with neostigmine at 14.8 (±6.1) min ( P < .0001; mean difference, 11.3 minutes; 95% confidence interval [CI], 9.0-13.5 minutes). There were no major adverse events in either group.

Conclusions: In patients with severe renal impairment, neuromuscular blockade with rocuronium followed by reversal with sugammadex provides a significantly faster return of neuromuscular function compared to cisatracurium and neostigmine, without any major adverse effects.

https://www.sciencedirect.com/science/article/abs/pii/S0952818026000243

Sugammadex was not associated with a significantly increased risk of pulmonary, cardiovascular, or mortality outcomes compared with neostigmine in patients with severe CKD having elective gastrointestinal surgery. Given the potential residual confounding by unmeasured factors such as surgical complexity, randomized controlled trials are needed to confirm these findings.

Safety of Sugammadex in Pregnancy, Pediatrics, and Renal Failure

In 2023, the American Society of Anesthesiologists published practice guidelines for the monitoring and antagonism of neuromuscular blockade. The guidelines recommended quantitative monitoring over...

www.apsf.org

The study demonstrated sugammadex’s superiority, achieving Train-of-Four Ratio (TOFR) >90% significantly faster (3.5±1.6 min) compared to neostigmine (14.8 ± 6.1 min), without major adverse events. This suggests that the use of sugammadex to reverse moderate blockade is safe and faster than a combination of neostigmine/cisatracurium in renally impaired patients.

I get that its a small population of esrd patients that may take time to fully evaluate. But the clinical evidence in daily practice is immediately apparent. Combined with initial studies showing no issues and the potential issues are largely theoretical...i am not worried about it

 

[Burned_Out]

Not really. Many studies show that clinicians are terrible at calculating TOF ratios and they dont measure tetany consistently.

Pretty rare to need more than 60-70mg roc for a case

Never heard of these studies. Sounds like they picked poor test subjects to do the TOF monitoring. “Rare” is a good generalization but I don’t generalize everyone and expect all to behave the same way to my anesthetic.

 

[pgg]

But you still do check TOF with the qualitative monitors at least? Even after sugammadex reversal?

I almost always check prior to reversal. (In some cases, e.g. single intubation dose of roc, low risk patient, longer case, patient already breathing spontaneously, I don't always check but I do always give sugammadex.)

Will sometimes check afterwards as well. Depends on overall risk. Usually not.

I grew up with neostigmine and residual blockade was a common issue. It can of course still be an issue in this new era of sugammadex, but I've only ever encountered it in people who were at particularly high risk, and/or got multiple redoses of NMBD, and/or still had dense blockade at the time of reversal. None of these issues require quantitative TO4 to safely manage.


As for renally impaired patients, I almost never use cis-atracurium. I'll just quote the roc package insert:

Due to the limited role of the kidney in the excretion of rocuronium bromide, usual dosing guidelines should be followed. In patients with renal dysfunction, the duration of neuromuscular blockade was not prolonged; however, there was substantial individual variability (range, 22 to 90 minutes).

I will put forth the opinion that cis should NOT routinely be used in the average renal patient, and that doing so carries HIGHER risk of residual blockade after surgery, because you're stuck reversing with neostigmine instead of sugammadex.