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I can't keep up with the rapid fire posting in this thread....
Seriously... It blew up pretty quickly.

I can't keep up with the rapid fire posting in this thread....
Seriously... It blew up pretty quickly.
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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.
Just think how lively this would be if Jet hadn't been censored and then had his ability to post eliminated once he returned.![]()
Jet is free to post at any time.
This from the mod that had no idea that he couldn't post.
Just think how lively this would be if Jet hadn't been censored and then had his ability to post eliminated once he returned.![]()
This from the mod that had no idea that he couldn't post. Maybe you are just a pawn for the admins. Just a thought.![]()
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?
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.
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.
Anesthesiology. 2010 Dec;113(6):1280-8.
Neostigmine/glycopyrrolate administered after recovery from neuromuscular block increases upper airway collapsibility by decreasing genioglossus muscle activity in response to negative pharyngeal pressure.
Herbstreit F, Zigrahn D, Ochterbeck C, Peters J, Eikermann M.
Source
Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Germany. [email protected]
Abstract
BACKGROUND:
Reversal of residual neuromuscular blockade by acetylcholinesterase inhibitors (e.g., neostigmine) improves respiratory function. However, neostigmine may also impair muscle strength. We hypothesized that neostigmine administered after recovery of the train-of-four (TOF) ratio impairs upper airway integrity and genioglossus muscle function.
METHODS:
We measured, in 10 healthy male volunteers, epiglottic and nasal mask pressures, genioglossus electromyogram, air flow, respiratory timing, and changes in lung volume before, during (TOF ratio: 0.5), and after recovery of the TOF ratio to unity, and after administration of neostigmine 0.03 mg/kg IV (with glycopyrrolate 0.0075 mg/kg). Upper airway critical closing pressure (Pcrit) was calculated from flow-limited breaths during random pharyngeal negative pressure challenges.
RESULTS:
Pcrit increased significantly after administration of neostigmine/glycopyrrolate compared with both TOF recovery (mean ± SD, by 27 ± 21%; P = 0.02) and baseline (by 38 ± 17%; P = 0.002). In parallel, phasic genioglossus activity evoked by negative pharyngeal pressure decreased (by 37 ± 29%, P = 0.005) compared with recovery, almost to a level observed at a TOF ratio of 0.5. Lung volume, respiratory timing, tidal volume, and minute ventilation remained unchanged after neostigmine/glycopyrrolate injection.
CONCLUSION:
Neostigmine/glycopyrrolate, when administered after recovery from neuromuscular block, increases upper airway collapsibility and impairs genioglossus muscle activation in response to negative pharyngeal pressure. Reversal with acetylcholinesterase inhibitors may be undesirable in the absence of neuromuscular blockade.
Anesthesiology. 2010 Dec;113(6):1280-8.
Neostigmine/glycopyrrolate administered after recovery from neuromuscular block increases upper airway collapsibility by decreasing genioglossus muscle activity in response to negative pharyngeal pressure.
Use of Reversal Drugs to Reduce Residual Paralysis
Interesting. Next time I administer rocuronium infusion without anesthesia (the study protocol) I won't reverse.
Interesting. Next time I administer rocuronium infusion without anesthesia (the study protocol) I won't reverse.
Yes, I do understand that these were healthy, young adults with no anesthesia on board. In addition, the study was under-powered in my opinion.
Again, I'm trying to present the facts for safe, effective care of patients who have received NMB in the O.R. I couldn't leave out that study.
But, there are at least a half dozen other studies showing the benefit of reversal. Again, I'm a proponent of low dose reversal in the right setting. I use more low dose reversal than any other dosage in my practice. I used to use 20 ug/kg routinely but over the past 24 months have dropped back to 10-15 ug/kg.
Those who give FULL DOSE REVERSAL to everyone should consider the evidence presented on this thread about reducing the dosage. Those who don't reverse at all should consider the evidence about the importance of low dose reversal.
Just a CA-1 here
I don't reverse everyone. Some attendings have more/less strong opinions about this. I base my reversal dosing from Baby Miller. I usually give neo at 50mcg/kg for 1-2 twitches. As low as 20mcg/kg for 4 with fade. I started using smaller doses for reversal after I saw another resident cause paradoxical weakness with a full reversal dose in a patient with 4 twitches and fade. Anyone else ever seen this?
Just a CA-1 here
I don't reverse everyone. Some attendings have more/less strong opinions about this. I base my reversal dosing from Baby Miller. I usually give neo at 50mcg/kg for 1-2 twitches. As low as 20mcg/kg for 4 with fade. I started using smaller doses for reversal after I saw another resident cause paradoxical weakness with a full reversal dose in a patient with 4 twitches and fade. Anyone else ever seen this?
And my reversal dosing from baby miller comes from chapter 12, table 12-7.
Based off this article...
http://www.ncbi.nlm.nih.gov/pubmed/1416176
I remember starting out CA-1 and some of my classmates gave full reversal to everyone. I used this chart, and haven't had a problem yet. Not sure if these are up to blade standards, but it's all I got. Curious what blade and others think about paradoxical weakness. Anyone else seen it?