Nmb reversal agents

Started by caveat87
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caveat87

caveat87

Full Member
15+ Year Member
The cost for nmb reversal with glyco and neostimgine is pretty high at my institution. People haven't adopted routine use of sugammadex for reversal of nmb. I tried using 0.8mg atropine today instead of glyco (atropine is about $10 for a stick while glyco is $30) with neo 2mg and the patient got pretty bradycardic suggesting maybe this wasn't enough. Was wondering if any of you use atropine routinely with neo for reversal and what dose works well.
 
caveat87 said:
The cost for nmb reversal with glyco and neostimgine is pretty high at my institution. People haven't adopted routine use of sugammadex for reversal of nmb. I tried using 0.8mg atropine today instead of glyco (atropine is about $10 for a stick while glyco is $30) with neo 2mg and the patient got pretty bradycardic suggesting maybe this wasn't enough. Was wondering if any of you use atropine routinely with neo for reversal and what dose works well.
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https://www.ncbi.nlm.nih.gov/pubmed/7196168

There is another excellent reversal combo: small muscle relaxant doses beyond induction (or none at all), and time. </wiseguy>
 
I think a combo of atropine and neostigmine is a great combo if you are desiring asystole in your patient. Maybe someone else wants to chime in on this. I mean we are talking 20 bucks. No comment. Especially when operating room time is so expensive that pennies in the bucket.
 
I've heard about this trend as well recently in a nearby institution. The quoted anaphylaxis rate for sugammdex is 0.3% on the drug insert. Are you willing to tolerate 1 in 200 rate of anaphylaxis? The routine use of this drug with that risk profile, coupled with it's own high cost, points against routine use in my opinion. Use the glyco and neo and call it a day.
 
facted said:
I've heard about this trend as well recently in a nearby institution. The quoted anaphylaxis rate for sugammdex is 0.3% on the drug insert. Are you willing to tolerate 1 in 200 rate of anaphylaxis? The routine use of this drug with that risk profile, coupled with it's own high cost, points against routine use in my opinion. Use the glyco and neo and call it a day.
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Check the dosages in the studies for hypersensitivity reactions. Thus far my institution's anaphylaxis rate is 0% since starting to use it almost exclusively a month after approval. To my knowledge we use 2/kg as basically the max dose unless they lack sufficient response, or 200 mg for big people.
You can always give more if you need to, so can start with low doses, which also have much lower risk profile.


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Also cost of sugga and neo/glyco is very similar as discussed in a previous thread. Check your neostig cost. It will surprise you.

The old school way to reverse is atropine/edrophonium.
 
Suggamadex is standard at my academic center with the exception of one faculty. We go up to 4mg/kg. We have used it since day one release and we are expected to use it any case we use roc. So far we haven't had any issues.
 
cincincyreds said:
I think a combo of atropine and neostigmine is a great combo if you are desiring asystole in your patient. Maybe someone else wants to chime in on this. I mean we are talking 20 bucks. No comment. Especially when operating room time is so expensive that pennies in the bucket.
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i'll chime in.
my current job, i usually reverse with neostigmine and atropine - works just fine, this was the standard reversal combination in the 90's when glyco was expensive
 
epidural man said:
Are the ones that are suggesting that atropine ISN'T a good option suggesting that atropine doesn't work as well as glycopryolate at raising the HR?
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Atropine acts earlier than glyco and neostigmine, hence the higher risk for bradycardia. And yes, it's also about half as potent as glyco.
 
Is may be the dosage of atropine was initially too low as it has been shown low dose atropine by itself produces bradycardia (http://circ.ahajournals.org/content/98/14/1394) . The cost of sugammadex 4mg/kg is around $130 for every reversal. Will the health care system continue to support such astronomically high costs for an anesthetic? Are other institutions outside of academia using sugammadex routinely?
 
epidural man said:
Are the ones that are suggesting that atropine ISN'T a good option suggesting that atropine doesn't work as well as glycopryolate at raising the HR?
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I think they're supposing that because it has a shorter duration, and neostigmine has a longer duration, that might create some risk of bradycardia later when they're not looking. (The old naloxone for hydromorphone reversal issue in the muscarinic side effect realm.)

Because there's no reason you can't titrate atropine + neostigmine with enough competence to avoid bradycardia at the time of administration.



Is edrophonium still marketed? I haven't seen it in years.
 
After neo became too expansive at my institution we switched back to atropine and edrophoniuim. Sometimes if there's no atropine in the cart, I'll just use glyco, but give it a little bit beforethe edrophonium
 
Aether2000 said:
Is may be the dosage of atropine was initially too low as it has been shown low dose atropine by itself produces bradycardia (http://circ.ahajournals.org/content/98/14/1394) . The cost of sugammadex 4mg/kg is around $130 for every reversal. Will the health care system continue to support such astronomically high costs for an anesthetic? Are other institutions outside of academia using sugammadex routinely?
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I use 1-2 mg/kg or 200 mg as max unless they remain weak. The cost is <10 dollars different than glyco and neo at my institution. I also feel it is a better drug. I dont recall exactly anymore, but said our costs a while ago in a different thread. somewhere around 80 or 90 for both options.
 
pgg said:
there's no reason you can't titrate atropine + neostigmine with enough competence to avoid bradycardia at the time of administration.
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i don't understand this discussion ...
just put 50mcg/kg neostigmine and 20mcg/kg atropine in one syringe and you're done.
 
Hey uh, generally speaking, how does one get a new/fancy drug like sugammades at the their hospital? Does the company approach the hospital? Go through Pharmacy committee etc? I want me some sugammadex.
 
fakin' the funk said:
Hey uh, generally speaking, how does one get a new/fancy drug like sugammades at the their hospital? Does the company approach the hospital? Go through Pharmacy committee etc? I want me some sugammadex.
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Generally you would go through pharmacy committee. It depends on your institution though. For us, I just called the head of pharmacy and asked him to look into it. Your hurdle is always going to be price and clinical effectiveness/other options. I had told him we probably wouldnt use it if it cost a lot more, we both were surprised at the lack of major price difference.
You may have to review the literature for him regarding the clinical benefits


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