Reverse everybody?

[Noyac]

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Some time back we had a discussion about whether every pt that received NMB needed to be reversed. Here is an article discussing this topic:

http://m.anesthesiologynews.com/Art..._id=1&i=ISSUE:+April+2012&i_id=830&a_id=20606

What are your attendings teaching you? What are your practice habits i( if you are out of training)?

Personally, I have never believed everyone needs reversal.

 

[soonerfrog]

Not to hijack the thread, but this is exactly why I was always so excited about the prospects of a drug like sugammadex. Talk about a designer pharm agent! These anti-ACh-ase drugs are one covalent step above poisons. How many PACU adverse events (PONV notwithstanding) could either be minimized or eliminated altogether by taking drugs like neostigmine out of the equation. I probably give 80-90% of patients at least some measure of reversal, but obviously it would be great to maximally reverse everyone while minimizing cholinergic side effects. I was always curious why so many had such an aversion to a drug like sugammadex unless it simply proved cost prohibitive. But even then, I'd like to think an extended PACU stay could help blunt or buffer any perceived increase in drug cost. Thoughts???

 

[periopdoc]

I would like to see a study administering neostigmine to patients who were never paralyzed looking at the same outcome measures.

Not every patient needs reversal.

We need better monitors for determining who does and doesn't require reversal.

-pod

 

[PMPMD]

.

 

[soonerfrog]

But I agree with Noy. Are there folks that are going to reverse a healthy, non-smoking female undergoing a lap GB with personal hx of PONV if she's pulling great 7-8mL/kg volumes? Does the chance of residual relaxation outweigh her need for giving her another emetic trigger? Who knows, but I'll frequently say no. You could always treat residual relaxation with reversal afterwards instead of giving EVERYONE unnecessary prophylaxis, IMO.

 

[olaf]

If it's been over an hour on someone healthy and they are pulling good tidal volume I don't normally give it. Haven't had to reintubate anyone because of it but have given reversal in the pacu two or three times if they look kinda floppy.

 

[dhb]

Since that discussion i've been more cautious about this:

-re dose= reversal (except rare very long case)
-mini dose (0.3mg/kg roc) = no reversal after 1h
-normal dose and intermediate duration: depends on clinical evaluation TOF

Otoh i avoid paralytics whenever possible.
I disagree that neostigmine causes a lot of PACU adverse events (just give zofran if you are concerned by ponv)

 

[jwk]

If it's been over an hour on someone healthy and they are pulling good tidal volume I don't normally give it. Haven't had to reintubate anyone because of it but have given reversal in the pacu two or three times if they look kinda floppy.

Are you using any other objective criteria for extubation? Tidal volume in and of itself is a poor one.

 

[periopdoc]

I disagree that neostigmine causes a lot of PACU adverse events

We don't know. It should be studied. I have seen enough weak patients in PACU who were given full dose reversal several hours after a single non-depolarizing dose should have worn off to pique my interest.

-pod

 

[Bertelman]

I disagree that neostigmine causes a lot of PACU adverse events (just give zofran if you are concerned by ponv)

Because that's some kind of PONV cure-all?

 

[Bertelman]

In the absence of other risk factors of hypoventilation, if I can show 4 full twitches for >1hr, I don't reverse. Haven't had any issues yet.

 

[dhb]

We don't know. It should be studied. I have seen enough weak patients in PACU who were given full dose reversal several hours after a single non-depolarizing dose should have worn off to pique my interest.

-pod

I meant when used properly

Because that's some kind of PONV cure-all?

You didn't know?

All i'm saying is after significant use of the "poison" i haven't witnessed the terrible damages it inflicts on innocent pacu patients

 

[sevoflurane]

To say that "everyone needs to get reversed" without a time context is simply wrong.

If I give 50mg of roc for a 3-4 bowel case... and are on SV at the end of the case with 800cc TV's and a RR of 8 and are forcefully reaching for the tube... then, WHY would I EVER give them neo/glyco? I don't even check a TOF with those patients.

 

[Noyac]

I have seen young anesthesiologist coming out of training give everyone that received NMB a full dose of reversal. Then not be able to extubate due to rapid shallow breathing and overall weakness. I have made the comment that the pt probably didn't need such a large dose of reversal and then the response frequently is "but that's what we did where I come from, we reverse everyone, fully".

I think they get in more trouble this way.

 

[BLADEMDA]

I have seen young anesthesiologist coming out of training give everyone that received NMB a full dose of reversal. Then not be able to extubate due to rapid shallow breathing and overall weakness. I have made the comment that the pt probably didn't need such a large dose of reversal and then the response frequently is "but that's what we did where I come from, we reverse everyone, fully".

I think they get in more trouble this way.

I reverse 99% of my patients. I have posted the literature on SDN to support that statement. Our Journals support my approach. Please put your studies on the safety of "non reversal" right here. I'll read them all (only one study exists by the way).

I use common sense as well. If it's Over 3 hours and they are healthy then I may consider skipping reversal. Under 2 hours and I reverse with a low dose after checking TOF.

I've never had a single patient get a complication from low dose reversal. Not one.

I'm aware that many of you skip reversal all too often at the patient's expense. You think that just because you can't see it then it doesn't exist. Doctors said the same thing about handwashing and bacteria for centuries.

The evience is clear we don't have routine mointors to evaluate TOF accurately. WE can't tell 0.6 from 0.9 with a standard twitch monitor.

Few of us have a TOF-Watch to actually see if reversal is warranted; hence, my predominant method of reversal is low dose in my practice.

We don't need to argue over this issue. The evidence is perfectly clear here. Spare me the anecdotal evidence (I have seen more "weakness" in PACU from non reversal) on the hazards of reversing non depolarizers.

 

[BLADEMDA]

 

[BLADEMDA]

In our opinion, these databases and our own review of many cases of adverse outcomes has led to the conclusion that reversal of NMB with neostigmine should be routine. Conversely, there should be written documentation as to why neostigmine was unnecessary.

Ron Miller, MD

 

[BLADEMDA]

Here is what we know today about non depolarizing NMBs:


1. Residual weakness after a single dose of intermediate NMBS is highly likely even with TOF/Tetany without fade.

2. Administration of low dose neostigmine is UNLIKELY and never been shown to cause a significant problem in HUMANS after receiving a NMB.
High dose or "standard" reversal may pose an issue in patients with a TOF of 0.9 or greater but low dose is unlikely to cause weakness.

3. Quantitative measurement of TOF with a device like TOF-Watch may allow the avoidance of reversal agents completely if a TOF of 0.9 or greater can be documented.

4. Now here is the kicker and why I firmly believe this thread is warranted:
If all you have in the operating room is standard twitch monitor then administering low dose reversal agents to patient with a TOF and tetany without fade is warranted based on our current body of knowledge.


Hence, Ron Miller, MD stated in the July Edition of Anesthesia and Analgesia the following statement:

The 3 excellent conclusions in the Viby-Mogensen and Claudius editorial include routine monitoring. We would add a fourth recommendation—routine administration of neostigmine or sugammadex (if available).


PeriopDoc 10/19/2010 on SDN

 

[Noyac]

Ok Blade, can you explain the results of the article I posted?

 

[Noyac]

Under 2 hours and I reverse with a low dose after checking TOF.
.

Please refer to my previous post were I described a younger anesthesiologist who was being instructed to "fully" reverse every pt that received NMB. By fully I mean, the full dose every time.

 

[sevoflurane]

I use common sense as well.

Yes. Common sense. Rocuronium has a 1/2 life of a little less than 18 minutes, which means that in 90 min. (Five 1/2 lives.) after an induction dose it should be gone in a healthy individual. You can be safe and reverse @ that point or even an hour later. But if you are giving 4-5mg of neostigmine @ 3-4 hrs. out... you are def. doing a diservice @ the patients expense.

I'm yet to have a floppy fish in the PACU. They wouldn't get extubated or make it out of my OR otherwise.

Complete reversal is particularly important for those of us who don't have "available" anesthesiologists to stomp out other peoples mistakes.

I'm confident that inappropriate neostigmine has made many patients weak.

So yeah.... use common sense.

 

[pgg]

The only people I DON'T reverse are patients who got a single intubating dose >2hrs ago and who have sustained tetany with the stim. Everyone else gets at least some neostigmine.

 

[Noyac]

Btw, I don't know so I will ask, when was the last time Ron Miller anesthetized a pt? I know Dr Miller (although I'm sure he doesn't know me or remember the cocktails we shared) and I'm sure he can perform an fantastic anesthetic but has he done this lately? I don't know.

 

[Noyac]

The only people I DON'T reverse are patients who got a single intubating dose >2hrs ago and who have sustained tetany with the stim. Everyone else gets at least some neostigmine.

Aren't you military? Do you do your own aesthetics? or do nurses do them for you?
And another question for you, what's the average age of your pts?

 

[sevoflurane]

Low dose is advisable for those who you suspect might have residual weakness within the context of the clinical scenario and what we know of the metabolism of a particular NMB.

10-20mcg/kg should do the trick in those who you assume are not fully reversed but are not overtly floppy or displaying other signs of more serious residuall weakness.

 

[Noyac]

Yes. Common sense. Rocuronium has a 1/2 life of a little less than 18 minutes, which means that in 90 min. (Five 1/2 lives.) after an induction dose it should be gone in a healthy individual. You can be safe and reverse @ that point or even an hour later. But if you are giving 4-5mg of neostigmine @ 3-4 hrs. out... you are def. doing a diservice @ the patients expense.

I'm yet to have a floppy fish in the PACU. They wouldn't get extubated or make it out of my OR otherwise.

Complete reversal is particularly important for those of us who don't have "available" anesthesiologists to stomp out other peoples mistakes.

I'm confident that inappropriate neostigmine has made many patients weak.

So yeah.... use common sense.

 

[BLADEMDA]

Ok Blade, can you explain the results of the article I posted?

Although the researchers did not expect this finding, they offered possible explanations. “With respect to monitoring, it must be that the combination of no monitoring or inconsistent monitoring and neostigmine reversal is associated with worse outcomes,” Dr. Eikermann noted. “And it has been shown by our group that if you give neostigmine in the absence of neuromuscular block, it decreases muscle strength. So we speculate that this is the mechanism, and clinicians just use reversal in patients who don’t really need it.”

 

[Noyac]

Although the researchers did not expect this finding, they offered possible explanations. “With respect to monitoring, it must be that the combination of no monitoring or inconsistent monitoring and neostigmine reversal is associated with worse outcomes,” Dr. Eikermann noted. “And it has been shown by our group that if you give neostigmine in the absence of neuromuscular block, it decreases muscle strength. So we speculate that this is the mechanism, and clinicians just use reversal in patients who don’t really need it.”

so if it decreases muscle strength and if you are more than 5 half-lifes from the point of administration then why give it?

 

[BLADEMDA]

Although the researchers did not expect this finding, they offered possible explanations. “With respect to monitoring, it must be that the combination of no monitoring or inconsistent monitoring and neostigmine reversal is associated with worse outcomes,” Dr. Eikermann noted. “And it has been shown by our group that if you give neostigmine in the absence of neuromuscular block, it decreases muscle strength. So we speculate that this is the mechanism, and clinicians just use reversal in patients who don’t really need it.”

Common Mistakes:

1) Reversal without a twitch. I know you studs think it's okay but I don't. No twitch meads inadaquate reversal is quite possible followed by a premature extubation leading to resp. problems in PACU.

2) Full dose reversal with TOF/Tetany without a fade- Recent study showed healthy volunteers given reversal (sig. dosage of Neostigmine) causes pharyngeal weakness.
Hence, Full dose when not needed may be just as harmful as item one listed above.

3) Overuse of Muscle relaxants- Common with Residents and some CRNAs. Leads to item number 1.


I'm going even lower with my low dose reversal technique these days. I use 10 mics/kg of Neostigmine with gylcco quite often when no signs of paralysis exist with standard moniotors.

POD's comments from 2010 till hold true today.

 

[lord_jeebus]

My goal is sustained tetanus for 5 seconds at 100 Hz. A full dose may or may not be necessary to achieve this.

The evidence I have seen (one, two) suggests that this is a reliable way to detect TOF approaching 0.9. The VA I rotate at has a kinetomyograph, and I have found my assessment of TOF > 0.9 using 100 Hz sustained tetanus to be highly accurate (and much less cumbersome than using the KMG). By contrast, I cannot differentiate TOF 0.65 from 0.9 on the KMG by visual assessment of standard TOF.

I have not seen good evidence that quantitative monitoring is any better than 100 Hz sustained tetanus - the papers that advocate their use limit the comparison to 50 Hz which has been shown to be inferior to 100 Hz.

 

[BLADEMDA]

so if it decreases muscle strength and if you are more than 5 half-lifes from the point of administration then why give it?

Fair enough. Although what is the half life in a patient age 80 with mild renal insuff? I doubt it's 18 min. Perhaps, you can consider low dose reversal in that subgroup at 2 hours?

My rule of thumb is about 2 hours from the last dose for any reversal. I seldom use full dose reversal any longer because I encourage judicious use of non depolarizers (avoid at the end of a case).

 

[BLADEMDA]

My goal is sustained tetanus for 5 seconds at 100 Hz. A full dose may or may not be necessary to achieve this.

The evidence I have seen (one, two) suggests that this is a reliable way to detect TOF approaching 0.9. The VA I rotate at has a kinetomyograph, and I have found my assessment of TOF > 0.9 using 100 Hz sustained tetanus to be highly accurate (and much less cumbersome than using the KMG). By contrast, I cannot differentiate TOF 0.65 from 0.9 on the KMG by visual assessment of standard TOF.

I have not seen good evidence that quantitative monitoring is any better than 100 Hz sustained tetanus - the papers that advocate their use limit the comparison to 50 Hz which has been shown to be inferior to 100 Hz.

I seldom use FULL DOSE REVERSAL ANY LONGER. It Isn't necessary. Try low dose and you will be suprised just how well it works with your sustained tetany model.

 

[Noyac]

Common Mistakes:

1) Reversal without a twitch. I know you studs think it's okay but I don't. No twitch meads inadaquate reversal is quite possible followed by a premature extubation leading to resp. problems in PACU.

2) Full dose reversal with TOF/Tetany without a fade- Recent study showed healthy volunteers given reversal (sig. dosage of Neostigmine) causes pharyngeal weakness.
Hence, Full dose when not needed may be just as harmful as item one listed above.

3) Overuse of Muscle relaxants- Common with Residents and some CRNAs. Leads to item number 1.


I'm going even lower with my low dose reversal technique these days. I use 10 mics/kg of Neostigmine with gylcco quite often when no signs of paralysis exist with standard moniotors.

POD's comments from 2010 till hold true today.

Not gonna argue point #1 with ya.
But let me ask some of the youngsters here, why is this the case?

I will say that I have gotten away with it tho.

 

[BLADEMDA]

To exclude residual paralysis, TOF, DBS, and 50-Hz tetanus are inadequate, 100-Hz tetanus is unreliable, and acceleromyography performs best.

http://www.anesthesia-analgesia.org/content/102/5/1578.abstract?

 

[pgg]

Aren't you military? Do you do your own aesthetics? or do nurses do them for you?
And another question for you, what's the average age of your pts?

I am military. I do all my own cases. In general there's no such thing as supervision/direction in the military.

.mil CRNAs do their own cases, generally without input from an anesthesiologist (though there is some scheduling bias, especially at the larger military hospitals, that keeps the sick/old/young in the physician rooms). Patient population is young and healthy, except for retirees, which are your standard old people.

I also moonlight - old, sick, and uninsured is the standard there. About 1/4 of the cases I do are at a civilian hospital.

 

[Noyac]

Fair enough. Although what is the half life in a patient age 80 with mild renal insuff? I doubt it's 18 min. Perhaps, you can consider low dose reversal in that subgroup at 2 hours?

My rule of thumb is about 2 hours from the last dose for any reversal. I seldom use full dose reversal any longer because I encourage judicious use of non depolarizers (avoid at the end of a case).

There you go throwing in the obvious exception to the subject at hand. 👍
Of course you are going to take the pts physical status into play. An 80 yo gets treated differently than a 20 yo healthy pt whether or not the 80 yo has renal insuff or not.

 

[Noyac]

I am military. I do all my own cases. In general there's no such thing as supervision/direction in the military.

.mil CRNAs do their own cases, generally without input from an anesthesiologist (though there is some scheduling bias, especially at the larger military hospitals, that keeps the sick/old/young in the physician rooms). Patient population is young and healthy, except for retirees, which are your standard old people.

I also moonlight - old, sick, and uninsured is the standard there. About 1/4 of the cases I do are at a civilian hospital.

Yeah I thought so!
Don't know how you can do that but its your life.

And with these young healthy pts, you still reverse them all, right? Really? You don't use your clinical judgement? Oh, yeah it s the military, I forgot.

 

[BLADEMDA]

To counteract the negative effects of neuromuscular blockade, anesthesiologists commonly turn to two strategies: objective monitoring and reversal with neostigmine at the end of the case. "Interestingly," Dr. Eikermann said, "only about half of our colleagues use any neuromuscular monitoring. The second interesting observation we made in this regard is that less than two-thirds use reversal."


What % of providers not using a twitch monitor gave full dose reversal? Now, what % of those patients getting full dose reversal were more than 30 minutes out from the last dose of Roc/Cis?

Those who do use twitch monitors routinely are giving full dose reversal despite TOF/Tetany without fade? Or, are they omitting the reversal altogether?

The answers to these questions are important to understand the findings in this study.

 

[Noyac]

To counteract the negative effects of neuromuscular blockade, anesthesiologists commonly turn to two strategies: objective monitoring and reversal with neostigmine at the end of the case. “Interestingly,” Dr. Eikermann said, “only about half of our colleagues use any neuromuscular monitoring. The second interesting observation we made in this regard is that less than two-thirds use reversal.”


What % of providers not using a twitch monitor gave full dose reversal? Now, what % of those patients getting full dose reversal were more than 30 minutes out from the last dose of Roc/Cis?

Those who do use twitch monitors routinely are giving full dose reversal despite TOF/Tetany without fade? Or, are they omitting the reversal altogether?

The answers to these questions are important to understand the findings in this study.

Agreed!

 

[lord_jeebus]

To exclude residual paralysis, TOF, DBS, and 50-Hz tetanus are inadequate, 100-Hz tetanus is unreliable, and acceleromyography performs best.

http://www.anesthesia-analgesia.org/content/102/5/1578.abstract?

I have read that study and it seems to be thrown off by a minority of cases where the TOF is lower than expected by the 100 Hz tetanus. If 100 Hz was so unreliable, I should be able to observe this in my own experience comparing KMG and tetanus, but in my experience I have never missed a TOF of < 0.85. My suspicion is that this study is limited by the participants who were observing the 100 Hz tetanus - which include "anesthesia residents and anesthesia assistants" with no specifics about their level of experience. They report missing a TOF of 0.14 which seems a little hard to believe for an experienced observer.

 

[pgg]

Yeah I thought so!
Don't know how you can do that but its your life.

And with these young healthy pts, you still reverse them all, right? Really? You don't use your clinical judgement? Oh, yeah it s the military, I forgot.

I give some degree of reversal to the majority of them. Nowhere did I say "all" - you said that, not me. I have specific criteria based on my reading of evidence and understanding of pharmacology. I'm open to changing my practice if you convince me otherwise, that's why I'm here.

And honestly I'd rather do my cases while the CRNAs did theirs, than direct or supervise.

I don't know how you guys put up with letting random people do your cases 4:1 while you try to anticipate their ****ups but it's your life. 🙂

 

[BLADEMDA]

Agreed!

Let me conclude with what I have been saying on SDN for years:

Low dose reversal with Neo/Glyc is the way to go if you have TOF. I still believe in using TOF/TOF and the CLOCK to decide if I'm going to give 10 ug/kg of Neostigmine to a patient. I believe low dose (esp. that very low dose) is safe and may enhance TOF recovery to greater than 0.9.

Full dose reversal should be limited to 1-3 twitches. If I don't have a twitch or inadaquate signs of any recovery from muscle relaxants I wait for a few minutes. I don't give full dose reversal unless there is at least one twitch. This has kept hundreds of patients and anxious CRNAS out of trouble in my practice. Despite some articles to the contrary I have seen floppy patients for hours in the PACU from premature reversal with full dose Neo/Glycc; additional reversal up to 70 ug/kg with Neo did not help.

POD's post from 2010 still holds true today.

 

[BLADEMDA]

I give some degree of reversal to the majority of them. Nowhere did I say "all" - you said that, not me. I have specific criteria based on my reading of evidence and understanding of pharmacology. I'm open to changing my practice if you convince me otherwise, that's why I'm here.

And honestly I'd rather do my cases while the CRNAs did theirs, than direct or supervise.

I don't know how you guys put up with letting random people do your cases 4:1 while you try to anticipate their ****ups but it's your life. 🙂

I"d rather do my own cases than supervise 4 rooms. Covering 4 rooms correctly is much harder than doing just one on your own.

 

[BLADEMDA]

I have read that study and it seems to be thrown off by a minority of cases where the TOF is lower than expected by the 100 Hz tetanus. If 100 Hz was so unreliable, I should be able to observe this in my own experience comparing KMG and tetanus, but in my experience I have never missed a TOF of < 0.85. My suspicion is that this study is limited by the participants who were observing the 100 Hz tetanus - which include "anesthesia residents and anesthesia assistants" with no specifics about their level of experience. They report missing a TOF of 0.14 which seems a little hard to believe for an experienced observer.

You do realize that millions of patients had safe anesthesia when the TOF ratio only had to be 0.7. Then it was 0.8. Now it is 0.9. My point is that I have no doubt you are reliably getting above 0.8 with your method; thus, how many patients would it take to show a difference between 0.8 and 0.9 clinically? 100,000? 200,000?

Using your method combined with a 2 hour time frame since the last dose seems solid.
But, avoiding the 10 ug/kg of Neostigmine when your monitor shows Tetany without fade for 5 seconds and the last dose of ROC was 36 min ago? I'm not so sure about that method. Perhaps, you are correct about NO DOSE reversal vs my LOW DOSE Reversal technique. I'll wait for more published data before getting fully on board.

 

[lord_jeebus]

But, avoiding the 10 ug/kg of Neostigmine when your monitor shows Tetany without fade for 5 seconds and the last dose of ROC was 36 min ago? I'm not so sure about that method.

I would also give a low dose in that scenario for peace of mind.

 

[Magoun]

I'm in my last year of training. In my residency (at a place that does tons of neuromuscular blocker research) the department encourages routine reversal, with full dose for one twitch dropping to ~20 mcg/kg at four twitches w no fade, unless you can document a tof ratio > 0.9 (in the one or that has a quantitative monitor). Alternatively you can document that it has been some undefined but long enough period of time with four twitches and you elected not to reverse.

That's not to say that that's what everyone does, but this was the official policy adopted when roc replaced cis in our trays due to shortage. (Yes, some people got into trouble with not reversing after the switch, hence the formal policy.)

 

[proman]

Yes. Common sense. Rocuronium has a 1/2 life of a little less than 18 minutes, which means that in 90 min. (Five 1/2 lives.) after an induction dose it should be gone in a healthy individual. You can be safe and reverse @ that point or even an hour later. But if you are giving 4-5mg of neostigmine @ 3-4 hrs. out... you are def. doing a diservice @ the patients expense.

I'm yet to have a floppy fish in the PACU. They wouldn't get extubated or make it out of my OR otherwise.

Complete reversal is particularly important for those of us who don't have "available" anesthesiologists to stomp out other peoples mistakes.

I'm confident that inappropriate neostigmine has made many patients weak.

So yeah.... use common sense.

I can't keep up with the rapid fire posting in this thread, but I'm with Blade on reversal. Couple of points: The distribution half life of roc is biphasic, with a rapid phase of 1-2 minutes and a slower phase of 14-18 min. This isn't however, its elimination half life. That is 60 to 80 minutes in healthy adults. In ESRD it could be over 120 minutes, which is why I don't use it. I fully agree that 5 half lives is enough to consider the drug gone, but you'd have to base it off elimination half life, not distribution.

When I dose neostigmine, it's at 0.07mg/kg. If it's been several hours, I typically give around 0.04mg/kg. There's really nothing to be gained by not reversing, and a potential brain dead patient if you don't. The risk-benefit ratio, to me, is strongly in favor of reversing almost everyone I plan on extubating, particularly if I'm using roc (highly variable recovery periods). What I haven't seen anyone mention is that the goal of reversal isn't to improve tidal volume or respiratory rate, but to ensure patency of the airway after removing the ET tube. We all know that the laryngeal muscles are extremely sensitive to blockade, but the extubation criteria is really based on the diaphragm mechanics.

 

[Noyac]

I don't know how you guys put up with letting random people do your cases 4:1 while you try to anticipate their ****ups but it's your life. 🙂

do you pay attention? I'm in an All MD practice. But if I had crna's doing cases I wouldn't be in a room for the sake of the pts that the nurses are trying to knock off. The military seems to think that this is ok I guess.

 

[Noyac]

When I dose neostigmine, it's at 0.07mg/kg. If it's been several hours, I typically give around 0.04mg/kg. There's really nothing to be gained by not reversing, and a potential brain dead patient if you don't. The risk-benefit ratio, to me, is strongly in favor of reversing almost everyone I plan on extubating, particularly if I'm using roc (highly variable recovery periods). What I haven't seen anyone mention is that the goal of reversal isn't to improve tidal volume or respiratory rate, but to ensure patency of the airway after removing the ET tube. We all know that the laryngeal muscles are extremely sensitive to blockade, but the extubation criteria is really based on the diaphragm mechanics.

seriously? Weakness, nausea, vomiting, tachycardia, ischemia are a few things that come to my mind.
If you are reversing a pt that doesn't need it, then you may be inducing weakness, No? So let me ask you something, if you don't reverse and the pt shows signs of weakness, does that mean you can't add reversal? You say potential brain death. Are you not a clinician that can tell when your pt may need assistance? Do you leave a pt in the pacu that you are not totally certain that they are safe?

 

[sevoflurane]

I can't keep up with the rapid fire posting in this thread, but I'm with Blade on reversal. Couple of points: The distribution half life of roc is biphasic, with a rapid phase of 1-2 minutes and a slower phase of 14-18 min. This isn't however, its elimination half life. That is 60 to 80 minutes in healthy adults. In ESRD it could be over 120 minutes, which is why I don't use it. I fully agree that 5 half lives is enough to consider the drug gone, but you'd have to base it off elimination half life, not distribution.

When I dose neostigmine, it's at 0.07mg/kg. If it's been several hours, I typically give around 0.04mg/kg. There's really nothing to be gained by not reversing, and a potential brain dead patient if you don't. The risk-benefit ratio, to me, is strongly in favor of reversing almost everyone I plan on extubating, particularly if I'm using roc (highly variable recovery periods). What I haven't seen anyone mention is that the goal of reversal isn't to improve tidal volume or respiratory rate, but to ensure patency of the airway after removing the ET tube. We all know that the laryngeal muscles are extremely sensitive to blockade, but the extubation criteria is really based on the diaphragm mechanics.

Elimination 1/2 life for ROC would mean the amount of drug that is physically removed from the body via hepatic/billiary/renal mechanisms. I'm more interested in distribution away from the neuromuscular junction. 5 elimination 1/2 live's of 60-80 minutes is way too conservative to use in the clinical environment IMHO. That's not mentioning the 30-40% that remains protein bound and never makes it to the neuromuscular junction in the first place. Good points to bring up though. Just my 2cents.