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