Pre-op rocuronium

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Random Resident said:
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.
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People overestimate the amnestic potential of versed. Not everyone gets amnesia, even with sturdy doses. I don't. I've been told by more than a few true believers that "they must not have given me enough." But I've had large doses several times now, and I can always accurately recount details of the procedures and the conversations in the room. It does provide some anxiolysis, so I'm not especially distressed by what I'm observing, but it doesn't seem to work at all to prevent me from retaining memories.

EDIT: Yes... the dose *could* always be increased to the point that it would no longer be "sedation." Making someone completely unconscious to the point of apnea with a benzo is probably a certain way to impair memory. Several different physicians and CRNAs have administered midaz at doses that they describe as being on the high end of their comfort level for a patient they didn't plan to intubate. I still remember them talking about whether they needed to bag me once, because my breathing had become so slowed. I also remember my slurred voice as I explained I was just comfortable and I would try to breathe more, if that would make them feel better.
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Random Resident said:
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.
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I find that zero mg of Versed is enough for most of my patients.
 
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Promethean said:
People overestimate the amnestic potential of versed. Not everyone gets amnesia, even with sturdy doses. I don't. I've been told by more than a few true believers that "they must not have given me enough." But I've had large doses several times now, and I can always accurately recount details of the procedures and the conversations in the room. It does provide some anxiolysis, so I'm not especially distressed by what I'm observing, but it doesn't seem to work at all to prevent me from retaining memories.

EDIT: Yes... the dose *could* always be increased to the point that it would no longer be "sedation." Making someone completely unconscious to the point of apnea with a benzo is probably a certain way to impair memory. Several different physicians and CRNAs have administered midaz at doses that they describe as being on the high end of their comfort level for a patient they didn't plan to intubate. I still remember them talking about whether they needed to bag me once, because my breathing had become so slowed. I also remember my slurred voice as I explained I was just comfortable and I would try to breathe more, if that would make them feel better.
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Yeah, I just thought it was interesting. I'm in ITE study mode, and it's hammered that it's an anterograde amnestic. Not so much for me. Definitely chilled me out, but I think twice now about the amnestic portion.
 
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Mman said:
The RN usually gives it over about 2 minutes.
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That doesn't sound so slow.

You do understand that the burn people are talking about is not at the iv site, right?

Not sure 2 minutes will make a difference.
 
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urge said:
That doesn't sound so slow.

You do understand that the burn people are talking about is not at the iv site, right?

Not sure 2 minutes will make a difference.
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<sarcasm>OMG, after 10+ years doing this I thought they were talking about it burning at the IV site. Thanks for clueing me in! </sarcasm>

On a more serious note, yes it is slow and yes it significantly decreases the perineal burning to the point of most patients not noticing it and the ones that do barely caring. Induction doses of propofol and etomidate cause more IV site pain than the perineal discomfort from a small dose of dexamethasone given slowly preop. Hell, our ENT surgeons routinely order 12-16 mg preop for patients and very few patients have any sort of complaint.

You act like it's some sort of torture method to give somebody preop dexamethasone. Are you just not good at knowing how to do it?
 
Maybe they don't complain about the dexamethasone burning because they like it and are into that kinky sort of thing.:eek:o_O
 
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Mman said:
<sarcasm>OMG, after 10+ years doing this I thought they were talking about it burning at the IV site. Thanks for clueing me in! </sarcasm>

On a more serious note, yes it is slow and yes it significantly decreases the perineal burning to the point of most patients not noticing it and the ones that do barely caring. Induction doses of propofol and etomidate cause more IV site pain than the perineal discomfort from a small dose of dexamethasone given slowly preop. Hell, our ENT surgeons routinely order 12-16 mg preop for patients and very few patients have any sort of complaint.

You act like it's some sort of torture method to give somebody preop dexamethasone. Are you just not good at knowing how to do it?
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Um, it is torture. It sucks.


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Random Resident said:
Um, it is torture. It sucks.
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I guess that's why I've seen so many patients not mention it while it's happening. They must all be Navy Seals. Hell, I've had more patients ask for it because it helped last time than I had complain about it burning.
 
Mman said:
I guess that's why I've seen so many patients not mention it while it's happening. They must all be Navy Seals. Hell, I've had more patients ask for it because it helped last time than I had complain about it burning.
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You did say the RN is the one who gives it.

I don't expect for you to see anyone complain about it.
 
urge said:
You did say the RN is the one who gives it.

I don't expect for you to see anyone complain about it.
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I'm often standing there while it is being given so I've personally witnessed thousands of administrations.
 
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A resident in our system gave Roc instead of Versed to a donor kidney transplant out in pre-op holding. That resident is no longer doing anesthesia.
 
pgg said:
F (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).
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Sorry this fact is bull. Ive heard it hundreds of times so no offense against you. True rate of rise is more like 12 first minute then 4 each additional minute. Takes 3 minutes to get to a PaCO2 of 60 in an anesthetized patient, even faster rate of rise in an unanesthetized patient.

Just think about it, when you see EtCO2's in the 60s at the end of a case, do you really think that required 10 minutes of apnea? Thats a pretty long breath hold...

http://www.ncbi.nlm.nih.gov/pubmed/2516732

http://www.ncbi.nlm.nih.gov/pubmed/7933492
 
btbam said:
A resident in our system gave Roc instead of Versed to a donor kidney transplant out in pre-op holding. That resident is no longer doing anesthesia.
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Did the patient make it to the room just fine like in the OP story?
 
Mman said:
I guess that's why I've seen so many patients not mention it while it's happening. They must all be Navy Seals. Hell, I've had more patients ask for it because it helped last time than I had complain about it burning.
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No one said it didn't help. Why so angry bro?
 
btbam said:
A resident in our system gave Roc instead of Versed to a donor kidney transplant out in pre-op holding. That resident is no longer doing anesthesia.
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How does **** like that happen?
Folks just drawing stuff up without labeling and confusing them? If distracted by the RN who was prepping the room for whatever reason and If I had any question of what I'd just drawn up, it was tossed.
 
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btbam said:
A resident in our system gave Roc instead of Versed to a donor kidney transplant out in pre-op holding. That resident is no longer doing anesthesia.
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What happened next?

You can't leave us hanging like that!
 
C'mon, guys. No mortalities here. Mark that has a plus data point for the next AANA study. They're just as safe.
 
Random Resident said:
No one said it didn't help. Why so angry bro?
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If patients are having significant problems with perineal burning/discomfort, perhaps the person administering the med doesn't know what they are doing. I'm not mad, just questioning how people can have had such bad experiences with a med given so routinely without incident.
 
Spinach Dip said:
What happened next?

You can't leave us hanging like that!
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It's all second hand but I guess he pushed "2mg of versed" aka 20 of roc and the patient started saying she couldn't breath so they rushed back to the OR and induced. I think it took a bit to realize he actually had a roc syringe in his pocket instead of the versed. This same resident also did things like push nitro with glyco for reversal and used lidocaine jelly in the eyes instead of lacrilube on a long case, so needless to say this was the final straw.

Oh yea and the kidney donor was apparently a nurse, just for the icing on the cake.
 
btbam said:
It's all second hand but I guess he pushed "2mg of versed" aka 20 of roc and the patient started saying she couldn't breath so they rushed back to the OR and induced. I think it took a bit to realize he actually had a roc syringe in his pocket instead of the versed. This same resident also did things like push nitro with glyco for reversal and used lidocaine jelly in the eyes instead of lacrilube on a long case, so needless to say this was the final straw.

Oh yea and the kidney donor was apparently a nurse, just for the icing on the cake.
Click to expand...
:boom:
 
btbam said:
It's all second hand but I guess he pushed "2mg of versed" aka 20 of roc and the patient started saying she couldn't breath so they rushed back to the OR and induced. I think it took a bit to realize he actually had a roc syringe in his pocket instead of the versed. This same resident also did things like push nitro with glyco for reversal and used lidocaine jelly in the eyes instead of lacrilube on a long case, so needless to say this was the final straw.

Oh yea and the kidney donor was apparently a nurse, just for the icing on the cake.
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Crazy. But what's wrong w a little lido jelly in the eyes? I used to do that to myself on the reg during residency to help alleviate the pain from watching 3hr lap choles.
 
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kazuma said:
Crazy. But what's wrong w a little lido jelly in the eyes? I used to do that to myself on the reg during residency to help alleviate the pain from watching 3hr lap choles.
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Lol.

I certainly don't miss those 3am lap chole/appy cases. Doubt that ish flies in the real world though.
 
btbam said:
It's all second hand but I guess he pushed "2mg of versed" aka 20 of roc and the patient started saying she couldn't breath so they rushed back to the OR and induced. I think it took a bit to realize he actually had a roc syringe in his pocket instead of the versed. This same resident also did things like push nitro with glyco for reversal and used lidocaine jelly in the eyes instead of lacrilube on a long case, so needless to say this was the final straw.

Oh yea and the kidney donor was apparently a nurse, just for the icing on the cake.
Click to expand...

He drew roc in a 3cc syringe?
Nitro with glyco? Does Nitro come in a vial? We had large bottles for Nitro where I was.
 
Doctor4Life1769 said:
He drew roc in a 3cc syringe?
Nitro with glyco? Does Nitro come in a vial? We had large bottles for Nitro where I was.
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There are, or were, 10 ml vials with 50 mg of nitro if I remember correctly.
 
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005054%20Nitroglycerin,%205mgmL,%20SDV,%2010mL,%2025%20Vials%20per%20Tray%20McGuffMedical.com.jpg
 
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urge said:
005054%20Nitroglycerin,%205mgmL,%20SDV,%2010mL,%2025%20Vials%20per%20Tray%20McGuffMedical.com.jpg
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I think that's why they had removed the vials where I was.
There were folks who apparently confused vials all the time and changes had to be made.
Still doesn't look like a vial of neostigine color wise.
 
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Mman said:
If patients are having significant problems with perineal burning/discomfort, perhaps the person administering the med doesn't know what they are doing. I'm not mad, just questioning how people can have had such bad experiences with a med given so routinely without incident.
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It's a known side effect. Not "incident". Some people will burn no matter how slow. You can quit beating your chest about it. The preop vs intraop issue has to do with onset and duration and length of case, not whether they are conscious or not. 5-10 minutes between awake and asleep is not going to make much of a difference. Even 30 minutes isn't going to make a difference.
 
Doctor4Life1769 said:
He drew roc in a 3cc syringe?
Nitro with glyco? Does Nitro come in a vial? We had large bottles for Nitro where I was.
Click to expand...
We have versed in the 5mg/cc vial so I am guessing he diluted it to 1mg/cc so in a 5 cc syringe like 50 of roc and then pushed 2ccs. We get different color Neostigmine vials all the time so who knows about that.
 
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Random Resident said:
It's a known side effect. Not "incident". Some people will burn no matter how slow. You can quit beating your chest about it. The preop vs intraop issue has to do with onset and duration and length of case, not whether they are conscious or not. 5-10 minutes between awake and asleep is not going to make much of a difference. Even 30 minutes isn't going to make a difference.
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I feel for those who get steroid infusions due to MS flares.
 
Random Resident said:
It's a known side effect. Not "incident". Some people will burn no matter how slow. You can quit beating your chest about it. The preop vs intraop issue has to do with onset and duration and length of case, not whether they are conscious or not. 5-10 minutes between awake and asleep is not going to make much of a difference. Even 30 minutes isn't going to make a difference.
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Red man syndrome is a known side effect of vancomycin, yet if you give it slower somehow the incidence goes down. Perineal discomfort is a side effect of IV dexamethasone, yet if you give it slower the incidence goes down.
 
Mman said:
Red man syndrome is a known side effect of vancomycin, yet if you give it slower somehow the incidence goes down. Perineal discomfort is a side effect of IV dexamethasone, yet if you give it slower the incidence goes down.
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Mechanism of action is incredibly different
 
Mman said:
Red man syndrome is a known side effect of vancomycin, yet if you give it slower somehow the incidence goes down. Perineal discomfort is a side effect of IV dexamethasone, yet if you give it slower the incidence goes down.
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Giving vanco in 2 minutes reduces red man syndrome?
 
urge said:
Giving vanco in 2 minutes reduces red man syndrome?
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I suggest you read what you actually quoted from me. Then again I'm not the one apparently unaware of how to comfortably administer dexamethasone to an awake patient.
 
Random Resident said:
Mechanism of action is incredibly different
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and yet giving a medication slower can change the chances of a side effect. Odd how that happens. I think the word you are looking for is analogous.
 
Mman said:
I suggest you read what you actually quoted from me. Then again I'm not the one apparently unaware of how to comfortably administer dexamethasone to an awake patient.
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I'm just asking.

Don't get your panties in a bunch.
 
Random Resident said:
It's not analogous. You're being awfully argumentative about something you don't even administer.
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I've administered > 1000 doses myself. I wish I could teach you had to do it well, but apparently not.
 
RxBoy said:
Sorry this fact is bull. Ive heard it hundreds of times so no offense against you. True rate of rise is more like 12 first minute then 4 each additional minute. Takes 3 minutes to get to a PaCO2 of 60 in an anesthetized patient, even faster rate of rise in an unanesthetized patient.

Just think about it, when you see EtCO2's in the 60s at the end of a case, do you really think that required 10 minutes of apnea? Thats a pretty long breath hold...

http://www.ncbi.nlm.nih.gov/pubmed/2516732

http://www.ncbi.nlm.nih.gov/pubmed/7933492
Click to expand...

It looks like you're right. I wonder where the 6/2 rule came from. Still shows up on ITE/AKT exams ...
 
btbam said:
It's all second hand but I guess he pushed "2mg of versed" aka 20 of roc and the patient started saying she couldn't breath so they rushed back to the OR and induced. I think it took a bit to realize he actually had a roc syringe in his pocket instead of the versed. This same resident also did things like push nitro with glyco for reversal and used lidocaine jelly in the eyes instead of lacrilube on a long case, so needless to say this was the final straw.
Click to expand...

The real mystery is, did the pre-induction "sign in" / "time in" get done? Otherwise that resident would be in big trouble :cool:
 
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