Pre-op rocuronium

[leaverus]

http://russellmd.blogspot.com/

holy crap, that first story. theyre lucky their patient doesn't have recall and severe ptsd, at least so far. i'm sure this sort of thing has happened before at other places but i can't imagine bringing a 5cc syringe of anything out to holding as a premed. and another reason why i dont draw up my induction agents til the pt is in the room. my biggest fear, even more than death, is awareness in one of my patients.

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[drmwvr]

http://russellmd.blogspot.com/

holy crap, that first story. theyre lucky their patient doesn't have recall and severe ptsd, at least so far. i'm sure this sort of thing has happened before at other places but i can't imagine bringing a 5cc syringe of anything out to holding as a premed. and another reason why i dont draw up my induction agents til the pt is in the room. my biggest fear, even more than death, is awareness in one of my patients.

Never mentions whether or not they told the patient...

 

[pgg]

Never mentions whether or not they told the patient...

Appears they didn't, just hoped like hell for some retrograde amnesia.

 

[okayplayer]

http://russellmd.blogspot.com/

holy crap, that first story. theyre lucky their patient doesn't have recall and severe ptsd, at least so far. i'm sure this sort of thing has happened before at other places but i can't imagine bringing a 5cc syringe of anything out to holding as a premed. and another reason why i dont draw up my induction agents til the pt is in the room. my biggest fear, even more than death, is awareness in one of my patients.

What in the actual f&*(.

 

[urge]

http://russellmd.blogspot.com/

holy crap, that first story. theyre lucky their patient doesn't have recall and severe ptsd, at least so far. i'm sure this sort of thing has happened before at other places but i can't imagine bringing a 5cc syringe of anything out to holding as a premed. and another reason why i dont draw up my induction agents til the pt is in the room. my biggest fear, even more than death, is awareness in one of my patients.

Could not tell whether the patient had 50 or 20 mg of Roc.

I imagine by the outcome it was only 20.

Not the first time I hear this scenario.

 

[urge]

Read it again.

They claim 50 of Roc.

This scenario is totally made up. The patient would be dead by the time you get into the room.

There is something else that gives it away as made up. But it requires a Jedi Master anesthesiologist to recognize it.

But, yes it has happened before.

 

[urge]

Speaking of another thread, this anesthesiologist and his nurse better come up with some good explanation on why they think regularly inducing unconsciousness in holding is a goal to achieve.

The patient appeared to lose consciousness in the appropriate amount of time and as she entered the OR was apneic.

"In the appropriate amount of time. "

That would be never for me.

 

[deleted59964]

It's a .com.au url (Australian), yet talks of anesthesiologists and crna's ? Seems odd

Not sure about the US but standard practice here is to draw up nmba's in red 5 ml syringes. That gets rid of most of the chance for this kind of thing.

I have heard of people 'inducing' with Cephazolin and sux rather than thio and sux though

 

[deleted59964]

I'm surprised they didn't give ect a try while they were at it

 

[urge]

I'm surprised they didn't give ect a try while they were at it

With the defibrillator paddles.

Clear!

 

[Promethean]

Read it again.

They claim 50 of Roc.

This scenario is totally made up. The patient would be dead by the time you get into the room.

There is something else that gives it away as made up. But it requires a Jedi Master anesthesiologist to recognize it.

But, yes it has happened before.

Depends on how far you had to go to get into the room. Our holding area was 20 feet from the nearest OR. I've seen a lot of meds pushed as the stretcher started rolling. So, if you are just counting on downtime as a measure of likelihood, I don't think that is entirely implausible.

They don't say 50 of Roc. They say 5 mL. It would be interesting to know the mg dose. I've seen dilutions used before.

The one thing that jumps out at me is that Roc burns. I've seen some very deeply sedated folks attempt to jerk their arms away if it is given too quickly, without adequate pre med. I'd expect some reaction from a conscious, already very anxious patient getting it without any sedation.

 

[drmwvr]

The one thing that jumps out at me is that Roc burns.

So does midazolam

 

[rfv123]

Roc doesn't cross the BBB. Can't hit CNS receptors as implied at end of the story.

 

[deleted171991]

They could have also tried propranolol. It's used experimentally to prevent PTSD. My guess is that the high dose of sevo acted in a similar way (PTSD is associated with release of epinephrine).

 

[Random Anesthesiologist]

"There is no reason to believe that rocuronium induced amnesia or plays a role in amnesia or sedation. However, as NDMB do block acetyl choline receptors, and these are prominent in the brain, this possibility does have some merit."

I am confused by this statement.

 

[deleted59964]

"There is no reason to believe that rocuronium induced amnesia or plays a role in amnesia or sedation. However, as NDMB do block acetyl choline receptors, and these are prominent in the brain, this possibility does have some merit."

I am confused by this statement.

that's because it's a load of BS

 

[WholeLottaGame7]

Had a similar incident happen to a resident a couple years behind me in residency. Roc instead of fentanyl before a block. Ended up doing fine; was disclosed and followed up for awhile. I think it was actually psychologically harder on the resident it happened to than the actual patient.

 

[urge]

The one thing that jumps out at me is that Roc burns. I've seen some very deeply sedated folks attempt to jerk their arms away if it is given too quickly, without adequate pre med. I'd expect some reaction from a conscious, already very anxious patient getting it without any sedation.

Strong in the Force this guy is.

So does midazolam

This one not so much.

 

[leaverus]

It's a .com.au url (Australian), yet talks of anesthesiologists and crna's ?

huh? where'd you get that from? there's no .au and the "about" says the guy is in Texas.

 

[drmwvr]

Strong in the Force this guy is.


This one not so much.

My routine is giving versed to awake patients....roc, not so much.

 

[YGK]

The article says that they intended to give 2cc versed 2cc fentanyl as premedication in same day, that itself can cause apnea ! And roc 5 cc will kill you immediately, is it this the dose for RSI.

 

[PainDrain]

First off, this person is an absolute f@cking idiot for mixing Midaz, fentanyl, and decadron into a single syringe. There is a reason these meds should be given their own syringes and labels. Second, this anesthesiologist talks about there NOT being a way he knows of inducing retrograde amnesia.....WTF. Ever heard of scopolamine IV? I have given it to cardiac patients who were on deaths door and then dont even remember their first three days in the hospital, let alone the induction. This story sounds like compete BS.

 

[deleted171991]

First off, this person is an absolute f@cking idiot for mixing Midaz, fentanyl, and decadron into a single syringe. There is a reason these meds should be given their own syringes and labels. Second, this anesthesiologist talks about there NOT being a way he knows of inducing retrograde amnesia.....WTF. Ever heard of scopolamine IV? I have given it to cardiac patients who were on deaths door and then dont even remember their first three days in the hospital, let alone the induction. This story sounds like compete BS.

When was the last time you saw IV scopolamine?

http://www.drugs.com/drug-shortages/scopolamine-injection-39

 

[deleted59964]

huh? where'd you get that from? there's no .au and the "about" says the guy is in Texas.

The link takes me to a .au site --- must be some tricky interweb thingee that redirects people to local hosts based on their location ... Feel free to disregard for those in the land of the free

 

[PainDrain]

When was the last time you saw IV scopolamine?

http://www.drugs.com/drug-shortages/scopolamine-injection-39

I had it until about 3 months ago. It was just taken off our formulary.

 

[Spinach Dip]

At no time during her PACU stay did she indicate that she had any recall of having been unable to move prior to surgery.

I hate to barge in, but this is the line I found most interesting.

Anyone with any understanding of criminology will know that determining if the patient did/didn't have recall is dependent almost entirely on how the question is posed. Two extremes come to mind:

-1. The anesthesiologist(s) (or whoever) went to the patient after they were fully awake and conversing normally and asked directly if she recalled anything unusual/stressful during induction. Alternately, (in an effort to reduce the bias of the question), they could have asked what her last memory was before awaking in the PACU.

-2. The anesthesiologist(s) (or whoever) said absolutely nothing, waiting for the patient to bring up the subject herself. In this case, it is quite possible that the patient thought the paralysis she experienced was normal and did not want to say anything, out of fear that she would sound like she was being hysteric/irrational. AKA, it is possible she remembered it, but did not address it because they way the question was (or was not) posed.



Something to think about.

 

[urge]

I would imagine that severe hypercarbia and hypoxia are pretty good at reducing recall.

 

[pgg]

this anesthesiologist talks about there NOT being a way he knows of inducing retrograde amnesia.....WTF. Ever heard of scopolamine IV? I have given it to cardiac patients who were on deaths door and then dont even remember their first three days in the hospital, let alone the induction. This story sounds like compete BS.

I don't think anyone was suggesting that retrograde amnesia was impossible to obtain, just that it's less likely than anterograde amnesia. And even anterograde amnesia is not a sure thing.

Also, a cardiac patient on death's door is likely to remember zilch whether you gave them scopolamine or not.

 

[pgg]

I would imagine that severe hypercarbia and hypoxia are pretty good at reducing recall.

Fair point though to pick a nit with this thought experiment, I would bet that in a non-denitrogenated patient, hypoxia would kill neurons before hypercarbia got bad enough to impact cognition. (At 6 + 2 per minute after the first, even 10 minutes of apnea would only put the patient's CO2 in the 60s ... probably not even that bad since hypoxia has a way of stunting CO2 production).

 

[WholeLottaGame7]

The article says that they intended to give 2cc versed 2cc fentanyl as premedication in same day, that itself can cause apnea ! And roc 5 cc will kill you immediately, is it this the dose for RSI.

Our regional guys in residency gave pretty much everyone 2 of midaz, 100 of fentanyl, and 20 of prop. There was some occasional apnea but not as much as you'd think. I did stop caring about people getting their panties in a bunch about not doing blocks under GA, though.

And 50 of roc is only the RSI dose for someone if they weigh 40kg, we don't see too many of those patients in the South. It is enough to do pretty much anyone in, though. The guy that it happened to in residency probably weighed a good 90kg, and 20 of roc was plenty to cause significant problems.

 

[Urzuz]

Our regional guys in residency gave pretty much everyone 2 of midaz, 100 of fentanyl, and 20 of prop.

That's a tad overboard IMO. The sedation I give is completely dependent on age/sex/build and baseline anxiety. I'll give most normal, young patients without anxiety and who are visibly cooperative 1 mg of midazolam and 25 mcg of fentanyl. Less for older patients, more for people who are freaking out. I think a lot of anesthesiologists tend to think that these blocks are extraordinarily uncomfortable and patients need to be snowed for them, when in reality they aren't (and not to mention that having a zonked out patient defeats the primary purpose of doing it before induction).

As an aside, it really bothers me when people give the same dose or do things the exact same way in every patient without thinking through why they are doing something or what they are trying to accomplish (eg: giving 2 mg of midazolam to every patient who rolls back in a gurney, no matter how much they are freaking out/how cool as a cucumber they are. What the eff is so special about 2 mg?). Just one of my pet peeves.

 

[Mman]

Read it again.

They claim 50 of Roc.

This scenario is totally made up. The patient would be dead by the time you get into the room.

Since they don't mention the distance to travel from the preop holding bedspace to the OR nor the time that elapsed, it's quite possible an ASA 1 patient would not be dead in that time frame. I'm guessing it was one of those talk to the patient, push some extra drugs and roll down the hallway sort of situations. ASA 1 patient on room air probably won't desat to < 90% for 60 seconds or so.

 

[Random Anesthesiologist]

I wouldn't give Decadron iv to an awake patient in preop just for nausea ppx. Especially a female. It burns like fire, and not at the iv site.

 

[Mman]

I wouldn't give Decadron iv to an awake patient in preop just for nausea ppx. Especially a female. It burns like fire, and not at the iv site.

Not if you give it slow and especially if they've already had midazolam.

 

[Random Anesthesiologist]

Not if you give it slow and especially if they've already had midazolam.

You've never had it, have you. Seriously. Like hellfire. Also, interestingly experienced versed as a patient last month. Not sure how much they gave me, but it wasn't enough. I remember the whole "sedated" procedure.

 

[Mman]

You've never had it, have you. Seriously. Like hellfire. Also, interestingly experienced versed as a patient last month. Not sure how much they gave me, but it wasn't enough. I remember the whole "sedated" procedure.

nope, but I've given or ordered it for probably 5000+ patients. Give it slow and give it after the versed and it's almost never an issue. Causes less discomfort than an induction dose with propofol or etomidate.

 

[urge]

Not if you give it slow and especially if they've already had midazolam.

How do you give decadron slow?

 

[psychbender]

How do you give decadron slow?

You can do what the dentists do, and order it in 100mL, to infuse over several minutes.

Or, you can just give it as part of your induction cocktail, and not worry about the burning, as they'll be out before it hits.

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[Random Anesthesiologist]

You can do what the dentists do, and order it in 100mL, to infuse over several minutes.

Or, you can just give it as part of your induction cocktail, and not worry about the burning, as they'll be out before it hits.

Sent from my SM-G920V using SDN mobile app

Who really gives Decadron in 100ml bags? Not me. Induction is one thing, preop is another. Most people push it, and it's not a friendly feeling if you're awake. Which is why I don't give it in preop for nausea. I noticed it was part of the preop cocktail in the story.

 

[psychbender]

Our oral surgeons like to order it like that, and I keep telling them I'll just push it with induction, and save the pharmacy some trouble mixing it. Their residents are just lazy, and highlight everything in their order sets without fail. They apparently do it that way in their clinic, too. But you are correct, because of the burning, and the fact that I can just give it with induction, I don't see a reason to give it as a premed.

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[BLADEMDA]

nope, but I've given or ordered it for probably 5000+ patients. Give it slow and give it after the versed and it's almost never an issue. Causes less discomfort than an induction dose with propofol or etomidate.

I've ordered about 20,000 doses of Decadron IV to patients in holding during my career. If the dosage is kept to 4 mg IV or less the side-effects are mild if any. My observed incidence of severe burning/itching from this dosage is less than 0.5% (undiluted) and 0% when diluted with NS or LR. However, if the dosage is increased to 8 mg or higher the incidence of perineal/anal burning is much higher around 5-10% (undiluted).

And I've had decadron IV push multiple times as a patient in the preop holding area without any issues.

 

[Doctor4Life1769]

I don't see the point in giving decadron while in preop as opposed to giving it at induction 3-5 mins later.

 

[Random Anesthesiologist]

I've ordered about 20,000 doses of Decadron IV to patients in holding during my career. If the dosage is kept to 4 mg IV or less the side-effects are mild if any. My observed incidence of severe burning/itching from this dosage is less than 0.5% (undiluted) and 0% when diluted with NS or LR. However, if the dosage is increased to 8 mg or higher the incidence of perineal/anal burning is much higher around 5-10% (undiluted).

And I've had decadron IV push multiple times as a patient in the preop holding area without any issues.

I wonder if you notice a difference between male and female response. 4 mg burned. Mag sulfate burns too.

As a side note, I experienced propofol for the first time a year ago. I stopped telling people they'd "feel a little tingle" after that.

 

[urge]

I've ordered about 20,000 doses of Decadron IV to patients in holding during my career. If the dosage is kept to 4 mg IV or less the side-effects are mild if any. My observed incidence of severe burning/itching from this dosage is less than 0.5% (undiluted) and 0% when diluted with NS or LR. However, if the dosage is increased to 8 mg or higher the incidence of perineal/anal burning is much higher around 5-10% (undiluted).

Do you see any problems with the credibility of your statistics?

You should.

1 You did not personally administer the drug. You could have been in the lounge, or busy somewhere else. You don't know how many of those patients complained but your nurse didn't tell you anything.
2 You don't know how many patients had a burning who-ha but chose not to say anything out of shame.

So whatever you think the incidence is, multiply it by at least 20.

 

[urge]

You can do what the dentists do, and order it in 100mL, to infuse over several minutes.

That's not the point. Of course you could give it very slowly if you wanted.

The point is who the hell does that?

I can smell bull **** from miles away.

 

[Doctor4Life1769]

No point to Dilute it in a 100cc bag.
If you really feel the urge to inject it pre-induction, just dilute it in 5 or 10cc NS.
Hell, throw in some fentanyl and Midaz. Don't forget the lidocaine for the propofol burn!
Sounds like what that bozo CRNA tried to do.
Unsure why the discussion is now about preop decadron.

 

[kazuma]

I wouldn't give Decadron iv to an awake patient in preop just for nausea ppx. Especially a female. It burns like fire, and not at the iv site.

It burns and itches in males too. A nurse gave me 10mg decadron IV before an MRI. As the transporter was pushing me to the scanner I suddenly felt the burn and itch in that special place. It wasn't horrible and it resolved after a few minutes.

 

[Mman]

How do you give decadron slow?

really? You push a little, pull back some saline, push a little more, pull back some saline, push a little more, etc. Do you really not know how to administer a med slowly?

 

[Mman]

I don't see the point in giving decadron while in preop as opposed to giving it at induction 3-5 mins later.

I believe the literature is stronger for preventing PONV when given preop.

 

[urge]

really? You push a little, pull back some saline, push a little more, pull back some saline, push a little more, etc. Do you really not know how to administer a med slowly?

How long do you take?