Succinylcholine gtts

[snowman8]

Anyone ever use a Sux gtts? Used it for the first time yesterday for a rigid bronch. Couple questions?

1. What dose and what duration can you use it for before you get a phase 2 block? I've heard 6-10mg/kg (wide range) and if used for duration of 30 min or longer.

2. Considering #1, what is the maximal dose you will use? My attending would not use more than 4mg/kg

3. What is the down side to a phase 2 block? Can it be reversed? According to Barash, it can

Your opinions

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[pgg]

3. What is the down side to a phase 2 block? Can it be reversed? According to Barash, it can

Although you sometimes can reverse a phase II block from succinylcholine, that's a different issue than whether or not you should. Miller (6th ed, p 871) is rather specfic about discouraging attempts at reversal.

The reversal response of a phase II block produced by a depolarizing muscle relaxant to administration of cholinesterase inhibitors is difficult to predict. It is therefore best that reversal by cholinesterase inhibitors is not attempted, although the response to tetanus or train-of-four stimulation resembles that produced by nondepolarizers.

The 1994 ITE had a question specifically addressing this, too:

A 60-kg, 38-year-old woman undergoes laparoscopic tubal ligation. Paralysis is maintained for one hour with infusion of succinylcholine at a rate of 10 mg/min. At the end of the procedure, respirations are shallow and tetanic fade is noted on neuromuscular stimulation. In addition to continued mechanical ventilation, which of the following is the most appropriate next step in management?

(A) Observe until the patient recovers spontaneously
(B) Monitor until PETCO2 reaches 50 mmHg
(C) Determine dibucaine number
(D) Administer fresh frozen plasma
(E) Administer glycopyrrolate and neostigmine

The key stated A was the correct answer.

 

[deleted126335]

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[Dejavu]

In the 70s and 80s, I routinely used succs gtts, especially for short cases. A great technique that I miss. Never ever saw a hint of phase 2 blocks, maybe due to length of surgeries I used it for.

I disagree that teaching is the only place for it. I think it is a great way to titrate relaxation. Presently we don't have it on our formulary so I no longer can do it.

Did read a case report back then of a pt where the succs gtt was left inline when the pt went to the floor (in the mark-your-own-drip days and before IV pumps). The floor people didn't want to waste the IV fluids so they hooked it up as the main IVF and walked away. Chilling words in the case report " It was assumed that awareness occurred before death".

 

[amyl]

wow thats awful.
i assume once suggamadex is on the market, sux drips will be mostly historical. anyone hear the latest when it will hit the market?

 

[Planktonmd]

I Presently we don't have it on our formulary so I no longer can do it.

You don't have Sux in your formulary?

 

[Gern Blansten]

Did read a case report back then of a pt where the succs gtt was left inline when the pt went to the floor (in the mark-your-own-drip days and before IV pumps). The floor people didn't want to waste the IV fluids so they hooked it up as the main IVF and walked away. Chilling words in the case report " It was assumed that awareness occurred before ".

I place 1 ml of methylene blue in the 250 bag so that no one will mistake it for any other "normal" IV drip. It forces them to read the label a little closer.

 

[Dejavu]

You don't have Sux in your formulary?

We do not have the powder form with 1000mg or 2000mg that I used to use to make my own.

 

[dfk]

wow thats awful.
i assume once suggamadex is on the market, sux drips will be mostly historical. anyone hear the latest when it will hit the market?

just talked to the rep today.
looks like september sugammadex will be out to around 1500 hospitals.
and in october (or so), zem will not be produced anymore, and will go generic (at 80% potency)

 

[Gern Blansten]

just talked to the rep today.
looks like september sugammadex will be out to around 1500 hospitals.
and in october (or so), zem will not be produced anymore, and will go generic (at 80% potency)

I am sure Rocuronium will still be made, but probably not marketed by organon as it has been in the past. Other companies will probably start to sell a cheaper version. Why would it be at "80% potency?"

 

[Planktonmd]

I am sure Rocuronium will still be made, but probably not marketed by organon as it has been in the past. Other companies will probably start to sell a cheaper version. Why would it be at "80% potency?"

Do you mean that the manufacturers of the generic Rocuronium will intentionally produce a less potent drug?
Does that make any sense to you?

 

[Gern Blansten]

Do you mean that the manufacturers of the generic Rocuronium will intentionally produce a less potent ?
Does that make any sense to you?

No sense at all. I can't imagine the FDA would allow that. I think he had some bad info from who he talked with. Probably just misunderstood it.

 

[dfk]

according to the rep, and i am quoting him, "most generics produced are at about 80% potency". i asked him why and there was no clear cut answer. it's similar in nature to vec(?) and propofol generics. they just aren't as good as pre-patent expiration.
makes no sense to me, but i'm sure that as long as the producers meet a certain "requirement" or percentage of effectiveness, they are "allowed" to move ahead. i'm no scholar in that arena, so don't really know how it all works.
and yea, i meant that organon won't make zem anymore.

 

[jwk]

according to the rep, and i am quoting him, "most generics produced are at about 80% potency". i asked him why and there was no clear cut answer. it's similar in nature to vec(?) and propofol generics. they just aren't as good as pre-patent expiration.
makes no sense to me, but i'm sure that as long as the producers meet a certain "requirement" or percentage of effectiveness, they are "allowed" to move ahead. i'm no scholar in that arena, so don't really know how it all works.
and yea, i meant that organon won't make zem anymore.

That still doesn't make sense to me. The whole concept of generics is supposed to be that a given drug is equivalent to it's name-brand counterpart. 10mg of rocuronium is still 10mg of rocuronium, regardless of the manufacturer, is it not?

 

[Arch Guillotti]

That still doesn't make sense to me. The whole concept of generics is supposed to be that a given drug is equivalent to it's name-brand counterpart. 10mg of rocuronium is still 10mg of rocuronium, regardless of the manufacturer, is it not?

10 mg is 10 mg all right but the potency can be different. Name brand and generics are essentially the same but not exactly. They have subtle difference in pharmacokinetics and pharmacodynamics, I guess because of differences in the manufacturing process. So one may not work as well as the other, though they are supposed to be the same thing.

 

[tussionex]

10 mg is 10 mg all right but the potency can be different. Name brand and generics are essentially the same but not exactly. They have subtle difference in pharmacokinetics and pharmacodynamics, I guess because of differences in the manufacturing process. So one may not work as well as the other, though they are supposed to be the same thing.

depending on what's being manufactured, there is a +/- margin that drug manufacturers are allowed to produce the product within. i used to work with someone who worked in manufacturing and the leniency can be suprising.
80% seems like a lot to me.
however, with drugs like DilantinKapseals (the brand name, PD stuff) they still hold the patent on the manufacturing process and the nature of phenytoin as a chemical makes producing generic phenytoin difficult and different enough that the 2 aren't quite considered "equivalent"

 

[dfk]

depending on what's being manufactured, there is a +/- margin that drug manufacturers are allowed to produce the product within. i used to work with someone who worked in manufacturing and the leniency can be suprising.
80% seems like a lot to me.
however, with drugs like DilantinKapseals (the brand name, PD stuff) they still hold the patent on the manufacturing process and the nature of phenytoin as a chemical makes producing generic phenytoin difficult and different enough that the 2 aren't quite considered "equivalent"

are you saying that 80% potency of the original is a lot?

 

[Mman]

according to the rep, and i am quoting him, "most generics produced are at about 80% potency". i asked him why and there was no clear cut answer. it's similar in nature to vec(?) and propofol generics. they just aren't as good as pre-patent expiration.
makes no sense to me, but i'm sure that as long as the producers meet a certain "requirement" or percentage of effectiveness, they are "allowed" to move ahead. i'm no scholar in that arena, so don't really know how it all works.
and yea, i meant that organon won't make zem anymore.

I think that rep was full of it myself.

The requirements for generics are identical to those for patented versions. Sure, there can be minor differences in composition of a compound produced by any plant, but we are talking teeny-tiny differences. I'd wager heavily that a clinician could never determine if a dose of Rocuronium was Zemuron or a generic equivalent. Hell, I'd be very suprised if Organon wasn't a large producer of generic Rocuronium for some time because they likely have the processing capacity to continue to produce it as cheaply as anybody else right now. Same product, new label.

 

[jetproppilot]

I think that rep was full of it myself.

The requirements for generics are identical to those for patented versions. Sure, there can be minor differences in composition of a compound produced by any plant, but we are talking teeny-tiny differences. I'd wager heavily that a clinician could never determine if a dose of Rocuronium was Zemuron or a generic equivalent. Hell, I'd be very suprised if Organon wasn't a large producer of generic Rocuronium for some time because they likely have the processing capacity to continue to produce it as cheaply as anybody else right now. Same product, new label.

I usta think generics=trademarked drugs.

Actually for the most part they probably are.

But there is a definite potency difference between the generic propofol being made today and Diprivan.

Additionally, the generic propofol makes many people cough before they go to sleep.

 

[KNC]

I usta think generics=trademarked drugs.

Actually for the most part they probably are.

But there is a definite potency difference between the generic propofol being made today and Diprivan.

Additionally, the generic propofol makes many people cough before they go to sleep.

hmm...., thats interesting.....why do people think that is?....

 

[dfk]

I usta think generics=trademarked drugs.

Actually for the most part they probably are.

But there is a definite potency difference between the generic propofol being made today and Diprivan.

Additionally, the generic propofol makes many people cough before they go to sleep.

i haven't seen many cough. perhaps it's because most of my patients get fentanyl in the preop and before induction. although, i did have one female cough the other day, and this was after 300 mg of the generic prop.

have any of you seen a non-equipotent effect of generic vec?

 

[tussionex]

i meant that a rep saying generics are made with 80% potency is basically selling the company yarn!

i will believe claims in potency/reponses/effects of drugs when i hear it from clinicians who actually have their hands on the patient. i'm more skeptical of a rep.


i have heard of the propofol thing, too. there is still some "sulfite free" diprivan made....i wonder if the sulfites in the propofol is the cause of the cough....

 

[SouthSideSteve]

Whats the difference between a drug rep and a used car salesman?

The used car salesman knows when he's lying to you.

 

[dhb]

generics don't have the same potency sometimes due to differences in absorbtion (in case of po meds), a lot of FP guys have seen a lesser control of BP or glycemia when changing patients from trademark to generic drugs.

 

[amyl]

by law, to be marketed as a generic version of a drug, the generic has to have 80% of the activity of the brand name.

 

[dfk]

there you go..
80% vs 90% vs 100% = saving money.
bottom line: the all mighty dollar.

 

[jetproppilot]

there you go..
80% vs 90% vs 100% = saving money.
bottom line: the almighty dollar..

I hate to break the philanthropic bubble of those of you out there in cyberspace with philanthropy left in you, but

the enhanced text above is what medicine revolves around current day.

Not patients.

Not doctors.

Accept it and earn a pretty good living.