Resistance to Roc

[Maverikk]

Anyone ever seen a total resistance to Roc? I had a case with an otherwise health 30 something for an I&D from uncontrolled brittle T1D, otherwise healthy. Versed makes the pt relaxed, prop puts them to sleep (ie IV working), I give Roc and ventilate for a bit, intubate and they buck but tube goes in, so I redose roc (now we're at about 1mg/kg). Pt just breathes through it the entire case, on minimal support with good tidal volumes. Anyone ever seen anything like this?

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[Iso4ane]

Never that bad, but between bad roc and an anticonvulsant, I’ve seen roc last a very very short period of time l.

 

[Psai]

Our roc is like water. I used to use 10 mg at a time but now I have to use 20 and it is at a more frequent interval as well. I think there's something wrong with the manufacturing.

 

[dhb]

I don't like roc too much variability and higher risk of anaphylaxis.

 

[dhb]

I think there's something wrong with the manufacturing

Or maybe since suggamadex they figured people would be less afraid to redose so they watered down the product.

 

[coffeebythelake]

Anyone ever seen a total resistance to Roc? I had a case with an otherwise health 30 something for an I&D from uncontrolled brittle T1D, otherwise healthy. Versed makes the pt relaxed, prop puts them to sleep (ie IV working), I give Roc and ventilate for a bit, intubate and they buck but tube goes in, so I redose roc (now we're at about 1mg/kg). Pt just breathes through it the entire case, on minimal support with good tidal volumes. Anyone ever seen anything like this?

I'm thinking quality control issues with the roc? The one made in India by Mylan is less potent than advertised. Add on to of this patient factors such as anticonvulsants and I can totally see this happening

 

[WholeLottaGame7]

Never that bad, but between bad roc and an anticonvulsant, I’ve seen roc last a very very short period of time l.

Had an epilepsy pt for VNS placement, on like 4 AEDs. Chewed through roc like you wouldn't believe.

I've also noticed some places refrigerate roc and others don't. I wonder if storage conditions affect potency.

 

[anbuitachi]

i once gave 50 mg of roc to a regular sized patient for induction, he didn't go apneic. gave another 50 and went apneic.

 

[drmwvr]

When roc was Zemuron, pharmacies kept much better care of it because sales reps were around to talk to the pharmacists and I assume because it was more expensive. Once it came off patent, I noticed that it became just another generic only it needed refrigeration. It sits around in carts out of the fridge and isn't rotated at all, at least where I am. That stuff really does expire. I used it all the time until I just gave up. Generic vecuronium is fresh every time and you can set your watch by it ( mostly)

 

[woopedazz]

Yesterday I gave 150mg (3 vials) for a skinny guy during 1 hour appendicectomy (junior registrar) and he was back to breathing with 4 twitches (slight degree of fade qualitatively) by the end of the case. I gave 50mg --> tubed with bucking --> redosed another 20mg --> apnoeic for <10 minutes --> redosed another 20 --> 20 --> 30 --> 10 near the end --> extreme confusion.

 

[vector2]

• Storage: Rocuronium Bromide Injection should be stored under refrigeration, 2-8°C (36 – 46°F) DO NOT FREEZE. Upon removal from refrigeration to room temperature storage conditions (25°C/77°F) use Rocuronium Bromide Injection within 60 days.

 

[btbam]

It's not "resistance" (unless they are on anti seizure meds), it's that the drug is literally degraded. We'd get Roc from India, put a twitch monitor on for induction, and guess what, twitches didn't go away. So either their manufacturing methods suck, or the shipments were sitting around in some hot warehouse for weeks before getting to us.

 

[Iso4ane]

It's not "resistance" (unless they are on anti seizure meds), it's that the drug is literally degraded. We'd get Roc from India, put a twitch monitor on for induction, and guess what, twitches didn't go away. So either their manufacturing methods suck, or the shipments were sitting around in some hot warehouse for weeks before getting to us.

That’s why I feel like there is a lot of variability between vials of Roc. I’ve come to the point that for longer cases I will draw up two 5cc vials of roc at a time to hopefully even things out a little.

 

[HLxDrummer]

What do you guys normally use for Roc dosing? In the ED I've done 1.2-1.6mg/kg right off the bat. Just surprised to see people talking about repeat doses getting to 1 mg/mg, 50mg, etc.

 

[2Fast2Des]

What do you guys normally use for Roc dosing? In the ED I've done 1.2-1.6mg/kg right off the bat. Just surprised to see people talking about repeat doses getting to 1 mg/mg, 50mg, etc.

Been using 20 to 30mg. Pharmacy isn't happy with sugammadex use as it's 8 fold more expensive apparently, so using neo\glyco is the only option and sugga is emergency only. I do 50mg and repeat dosing only for the anticipated long case

 

[pgg]

What do you guys normally use for Roc dosing? In the ED I've done 1.2-1.6mg/kg right off the bat. Just surprised to see people talking about repeat doses getting to 1 mg/mg, 50mg, etc.

A lot of us normally just use 30-50 mg because one 5 mL vial has enough for one patient, and it's fine for most cases.

1.6 mg/kg is a lot. A typical intubating dose is 0.6 mg/kg. RSI dose is 1.2 mg/kg. Keep in mind the ED95 is 0.3 mg/kg so even the textbook intubating dose is a lot.

 

[HLxDrummer]

Thanks for the info. Didn't occur to me but obviously you guys have different needs (timing, reversal, etc). When I'm using it, it is 100% RSI.

Regarding the 1.6 dose, just saw in one study it had a faster time of onset but agree it does seem high

 

[MirrorTodd]

How to do the anti-epileptics cause resistance to roc?

 

[nimbus]

Thanks for the info. Didn't occur to me but obviously you guys have different needs (timing, reversal, etc). When I'm using it, it is 100% RSI.

Regarding the 1.6 dose, just saw in one study it had a faster time of onset but agree it does seem high

Before sugammadex I would intubate most of my shorter cases (lap chole, lap appy) with roc 30mg. Once in awhile someone would cough after intubation but it was always enough to get the job done and I wouldn’t get burned with a patient who was too densely paralyzed to be reversed at the end of the procedure. Nowadays with sugammadex, I use 50mg of roc because that’s what comes in 1 vial.

 

[nimbus]

How to do the anti-epileptics cause resistance to roc?

https://www.sciencedirect.com/topics/neuroscience/anticonvulsants

 

[btbam]

How to do the anti-epileptics cause resistance to roc?

From a paper online:

Phenytoin induces hepatic enzymes, and it is likely that metabolism and elimination of the muscle relaxant is increased; increased clearance of muscle relaxants has been demonstrated after chronic phenytoin use. 6 Phenytoin also has effects that might alter the apparent sensitivity of the patient to circulating muscle relaxants. For example, it has mild blocking action at the neuromuscular junction, 7 which may lead to up-regulation of the acetylcholine receptor. 8 It also might alter the protein binding of muscle relaxants or have effects at presynaptic acetylcholine receptors. The relative contribution of these various possible mechanisms to this interaction is not known.

 

[woopedazz]

What do you guys normally use for Roc dosing? In the ED I've done 1.2-1.6mg/kg right off the bat. Just surprised to see people talking about repeat doses getting to 1 mg/mg, 50mg, etc.

There are side effects from "overdosing" roc, but it's pretty rare to run into them. Rocuronium is vagolytic (particularly on fast injection). There's a risk of pseudo-anaphylaxis (anaphylactoid) reactions with roc, which are much worse when given in large volumes and at speed. However, it's not as directly histaminergic as other NDMRs when there is no anaphylactoid reaction present.

 

[jwk]

Been using 20 to 30mg. Pharmacy isn't happy with sugammadex use as it's 8 fold more expensive apparently, so using neo\glyco is the only option and sugga is emergency only. I do 50mg and repeat dosing only for the anticipated long case

Your pharmacy is lying to you regarding the price, or their buyer is an idiot - or both. Sugammadex, in many places, is approaching being the standard of care. Not using it because of economic concerns is absurd.

 

[2Fast2Des]

Your pharmacy is lying to you regarding the price, or their buyer is an idiot - or both. Sugammadex, in many places, is approaching being the standard of care. Not using it because of economic concerns is absurd.

Our leadership told us that sugammadex is not the standard of care at this institution, all because the pharmacy doesn't want to cough up the moolah. Is there studies or evidence to show that sugammadex can speed up the extubation, OR, pacu, or ICU admission rate to show the pharmacy that they're being penny wise and pound foolish?

 

[shepardsun]

There are a slew of smaller retrospective studies that show a relatively decreased incidence of respiratory events in the PACU with sugammadex that some argue results in an overall cost savings from a system standpoint. I'm not aware of any large or landmark papers.

 

[jthedestroyr]

Suggamadex is standard at our institution in fact it came out when I was a ca1 and our class basically exclusively used it. To be honest, I had only used glyco/neo combo handful of times until our private practice osh rotation which doesnt uave suggamadex as our pharmacy is very pro suggamadex. The VA hospital is also very pro suggamadex here.

 

[TheLoneWolf]

Heard the same from old school attendings and crnas with a decade or over of experience in pp. When it was brand name zemuron, it worked like clockwork. The generic one from India is hit or miss. Some bad batches. Most still love vecuronium for its reliability but dislike masking for a few more mins.

 

[Psai]

Heard the same from old school attendings and crnas with a decade or over of experience in pp. When it was brand name zemuron, it worked like clockwork. The generic one from India is hit or miss. Some bad batches. Most still love vecuronium for its reliability but dislike masking for a few more mins.

It's only like one more minute

 

[deleted162650]

It's only like one more minute

Plus the extra 30s to reconstitute it. No thanks!

 

[abolt18]

Heard the same from old school attendings and crnas with a decade or over of experience in pp. When it was brand name zemuron, it worked like clockwork. The generic one from India is hit or miss. Some bad batches. Most still love vecuronium for its reliability but dislike masking for a few more mins.

I've got one attending who did PP for 18 yrs and all he uses is sux and cisatracurium for every case that requires paralytic beyond induction. For that exact reason of reliability and predictability.

 

[deleted162650]

I've got one attending who did PP for 18 yrs and all he uses is sux and cisatracurium for every case that requires paralytic beyond induction. For that exact reason of reliability and predictability.

That’s stupid . . . and lazy.

 

[abolt18]

That’s stupid . . . and lazy.

I've not worked with anyone else that uses cis on the regular, but I don't understand what's lazy about it?

 

[deleted162650]

I've not worked with anyone else that uses cis on the regular, but I don't understand what's lazy about it?

It’s really the sux part that’s lazy. That’s a lot of unnecessary myalgias. Ask @pgg about sux myalgias.

 

[pgg]

Ask @pgg about sux myalgias.

They suck.

 

[abolt18]

It’s really the sux part that’s lazy. That’s a lot of unnecessary myalgias. Ask @pgg about sux myalgias.

NSAIDS?

 

[coffeebythelake]

NSAIDS?

Not many surgeons would be happy with that suggestion

 

[abolt18]

Not many surgeons would be happy with that suggestion

I feel like a majority of the surgeons I've worked with are okay with toradol (in the appropriate patient). I always check before I give it. Obviously I don't even consider it in settings of decreased renal function, high bleeding risk, or bowel anastomosis.

 

[fakin' the funk]

Rocuronium is vagolytic (particularly on fast injection). There's a risk of pseudo-anaphylaxis (anaphylactoid) reactions with roc, which are much worse when given in large volumes and at speed.

Citations, please.

 

[nimbus]

I feel like a majority of the surgeons I've worked with are okay with toradol (in the appropriate patient). I always check before I give it. Obviously I don't even consider it in settings of decreased renal function, high bleeding risk, or bowel anastomosis.

I work with a bariatric surgeon asks for toradol for every single RYBG. His 2 partners never give it. They are all high volume surgeons. Never noticed a difference in outcome.

 

[woopedazz]

Citations, please.

Hmm... It was just stuff I knew. Here's some supporting evidence re: vagolytic:
1. https://academic.oup.com/bja/article-pdf/78/5/586/18260967/780586.pdf
2. Rocuronium chapter p. 344 of Drugs in Anesthesia and Intensive Care, 5th edition. Authors: Edward Scarth, Susan Smith.
"Rocuronium has minimal cardiovascular side effects; with large doses a mild vagolytic effect leads to a 9% increase in the heart rate and MAP of up to 16%."

Here's some direct quotes from an allergy journal re: rocuronium anaphylactoid reactions "Spoerl D: Non-IgE-Dependent Hypersensitivity to Rocuronium Reversed by Sugammadex: Report of Three Cases and Hypothesis on the Underlying Mechanism. Int Arch Allergy Immunol 2016;169:256-262. doi: 10.1159/000446182"
- Approximately 60% of perioperative hypersensitivity reactions are IgE-mediated anaphylactic reactions, whereas 40% are pseudoallergic (anaphylactoid) reactions.
- Under most circumstances, it is impossible to clinically distinguish an IgE-mediated allergic reaction from a pseudoallergic reaction.
- Rocuronium has been shown to activate the MRGPRX2 receptor on mast cells, inducing a non-IgE-mediated histamine release, which explains its potential for causing pseudoallergic reactions.

Anaphylactoid reactions (non-immune anaphylaxis or psudoanaphylaxis or whatever you want to call it) are target tissue concentration-dependent and therefore rate and dose-dependent.

 

[drmwvr]

There are side effects from "overdosing" roc, but it's pretty rare to run into them. Rocuronium is vagolytic (particularly on fast injection).

That was a property we exploited with another steroid based relaxant, pancuronium when we overdosed narcotic in cardiac anesthesia years ago. Now that "fast track" is common, we're not doing that, but nearly everyone takes a beta blocker now. A little heart rate can be helpful with even the smaller doses of narcotic some still use for induction.