Sugamma-f'n-dex

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sevoflurane

sevoflurane

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So far very impressed with this stuff.
Amazing how quickly you can go from 1/4 to 4/4.

Ear case. 45 minutes. 40 mg of Roc. SV mode at end of the case with 1/4 and 70 cc TV.
200mg of Sugamma-f'n-dex. 30 seconds later 650 TV's. Impressive.

Is everyone following 4mg/kg dosing?


IMG_9417_zpsrlatrsnm.jpg
 
sevoflurane said:
So far very impressed with this stuff.
Amazing how quickly you can go from 1/4 to 4/4.

Ear case. 45 minutes. 40 mg of Roc. SV mode at end of the case with 1/4 and 70 cc TV.
200mg of Sugamma-f'n-dex. 30 seconds later 650 TV's. Impressive.

Is everyone following 4mg/kg dosing?


IMG_9417_zpsrlatrsnm.jpg
Click to expand...

We were doing 4 if 1-2 post tenanic and 2 per if two twitches
 
sevoflurane said:
So far very impressed with this stuff.
Amazing how quickly you can go from 1/4 to 4/4.

Ear case. 45 minutes. 40 mg of Roc. SV mode at end of the case with 1/4 and 70 cc TV.
200mg of Sugamma-f'n-dex. 30 seconds later 650 TV's. Impressive.

Is everyone following 4mg/kg dosing?


IMG_9417_zpsrlatrsnm.jpg
Click to expand...
How much does that dose cost?
 
We have had it available for m this now and nobody has even cracked open a bottle.

Why all the use? Are you guys paralyzing more now that you have sugamma-f'in-dex?
 
Any thoughts on emergency use? I think I remember reading some article that claimed it still would take too long for a failed intubation situation and that likely patient would desat before returning to spontaneous.
 
Noyac said:
We have had it available for m this now and nobody has even cracked open a bottle.

Why all the use? Are you guys paralyzing more now that you have sugamma-f'in-dex?
Click to expand...

I wouldn't say we are using it a lot. But... $20-30 isn't breaking the bank either. I think we are all becoming familiar with this new player.

Had a case a couple days ago.

AF ablation in a sicko that couldn't lie flat. Very tachypnic HR 130's.
Intubated with 50mg of Roc.
Dropped a TEE and found a large clot in the LAA- case canceled.

0/4 twitches. Perfect case for it!

I think there is a general curiosity throughout our department. I can find myself using it in many situations.
 
linkin06 said:
Any thoughts on emergency use? I think I remember reading some article that claimed it still would take too long for a failed intubation situation and that likely patient would desat before returning to spontaneous.
Click to expand...

Higher dosage. 16mg/kg if I remember correctly.

The problem is, if you need to emergently reintubate them, you'll need a much higher dosage of roc.

Which brings me to another point of discussion. Contraindications and relative contraindications. There are many.
 
It does what it's supposed to do. It's reliable. I suppose if it prevents even 1 ICU admission in a year, it's already paid for itself and then some.
 
Ezekiel2517 said:
It does what it's supposed to do. It's reliable. I suppose if it prevents even 1 ICU admission in a year, it's already paid for itself and then some.
Click to expand...

Agree. It's only a matter of time before it becomes the reversal agent of choice. I predict sooner rather than later.
 
The correct dose if you have 1 twitch is 2 mg/kg; this means 90% of patients can be given low dose Sugammadex reversal. I've used it about 100 times so far and it is impressive. I agree it takes about 30 seconds for complete reversal.

The 4 mg/kg dosage is utilized if there are no twitches but a response to tetany burst. I've never needed more than 4 mg/kg and have only given that dosage once. The use of Neostigmine/Glyco is still acceptable if needed after the 2 mg/kg IV dosage of sugammadex. I am pointing this out in case you ever see or experience residual weakness after the sugammadex (rare) or vice-versa.

On occasions patients were still weak after "full reversal" with Neostigmine/Glyco but 2 mg/kg of sugammadex fixed that problem in 30 seconds flat. Typically, I just give the entire 200 mg bottle IV if the patient weighs more than 50 kg.
 
BLADEMDA said:
I think the drug rep told me 6 hours or so with normal renal function if one wants to use ROC again.
Click to expand...

5-6 hours or a much higher dose of roc. If you used .6mg/kg. you will need 1.2 mg/kg on the subsequent reintubation. Might have o check on that, but that is how I remember it.
 
Neostigmine + glyco should cost about $4 per dose. You have people like Pharma Bro who are putting old drugs on the market at exorbitant prices. Neostigmine has been around since the 1930s, but was recently remarketed as Bloxiverz at a ridiculous price.
 
We use it almost exclusively since about a month after it was approved. Thousands of cases. Cost for us is $16 different than the combo. It is just plain that much better that there is no reason to use a sloppy combination of drugs.

Almost always use the low dose of 2/kg. Only time you need more is if they are WAY over dosed on roc, which we do a fair amount more often for the really picky surgeons.
From what I have read, most issues are dose dependent, so these lower doses are safer. Really though, there is no issue with giving some, then giving more later if they are still weak, and the low dose does well enough even if they are pretty weak.

So far no noted side effects or increased issues in recovery room. In fact, we have better respiratory mechanics frequently, which goes along with the general consensus that we were not reversing people as much as we should before. PACU time is a little down overall last quarter, but we have been doing other stuff too. Nobody has come back and told us they became pregnant due to failed birth control yet either.

And yes, we just use cis when something unexpected happens.

Oh, and if you havent used it, hook up the quantitative twitch monitor at every 15 seconds and watch the reversal. You will be sold.


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pjl said:
We use it almost exclusively since about a month after it was approved. Thousands of cases. Cost for us is $16 different than the combo. It is just plain that much better that there is no reason to use a sloppy combination of drugs.

Almost always use the low dose of 2/kg. Only time you need more is if they are WAY over dosed on roc, which we do a fair amount more often for the really picky surgeons.
From what I have read, most issues are dose dependent, so these lower doses are safer. Really though, there is no issue with giving some, then giving more later if they are still weak, and the low dose does well enough even if they are pretty weak.

So far no noted side effects or increased issues in recovery room. In fact, we have better respiratory mechanics frequently, which goes along with the general consensus that we were not reversing people as much as we should before. PACU time is a little down overall last quarter, but we have been doing other stuff too. Nobody has come back and told us they became pregnant due to failed birth control yet either.

And yes, we just use cis when something unexpected happens.

Oh, and if you havent used it, hook up the quantitative twitch monitor at every 15 seconds and watch the reversal. You will be sold.


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Click to expand...

Same here, rarely using combo anymore. Per our pharmacist, cost difference is actually in favor of Suga.
 
BLADEMDA said:
The correct dose if you have 1 twitch is 2 mg/kg; this means 90% of patients can be given low dose Sugammadex reversal. I've used it about 100 times so far and it is impressive. I agree it takes about 30 seconds for complete reversal.

The 4 mg/kg dosage is utilized if there are no twitches but a response to tetany burst. I've never needed more than 4 mg/kg and have only given that dosage once. The use of Neostigmine/Glyco is still acceptable if needed after the 2 mg/kg IV dosage of sugammadex. I am pointing this out in case you ever see or experience residual weakness after the sugammadex (rare) or vice-versa.

On occasions patients were still weak after "full reversal" with Neostigmine/Glyco but 2 mg/kg of sugammadex fixed that problem in 30 seconds flat. Typically, I just give the entire 200 mg bottle IV if the patient weighs more than 50 kg.
Click to expand...
I thought a moderate block, defined as 3-4 twitches is 2mg/kg, a deep block (< or = to 2 twitches) twitches is 4mg/kg. Reversal of an RSI attempt with rocuronium is 16mg/kg.

Edit - our cost for neostigmine and glycopyrrolate is right at $100, and I believe we are paying $90 for a 200mg vial of sugammadex.
 
We use the 4-2-1 dosing. 1 post tetanic twitch gets 4mg/kg. 1-2 twitches is 2mg/kg. 3+ is 1mg/kg. The emergency dose for a failed airway is 16mg/kg, which usually exceeds the amount we have in the cart. However, last week I went in for emergence and I was told the surgeons kept on saying the patient needed to be more relaxed, so the CRNA kept on giving roc. Well a few minutes after they were done there was 1 post tetanic twitch. 4mg/kg and 60 seconds later we had 4/4 and the patient breathing spontaneously. Its a pretty cool drug!
 
RocurWorld said:
We use the 4-2-1 dosing. 1 post tetanic twitch gets 4mg/kg. 1-2 twitches is 2mg/kg. 3+ is 1mg/kg. The emergency dose for a failed airway is 16mg/kg, which usually exceeds the amount we have in the cart. However, last week I went in for emergence and I was told the surgeons kept on saying the patient needed to be more relaxed, so the CRNA kept on giving roc. Well a few minutes after they were done there was 1 post tetanic twitch. 4mg/kg and 60 seconds later we had 4/4 and the patient breathing spontaneously. Its a pretty cool drug!
Click to expand...

What do you do with the leftover sugammadex? We don't re-use the 2 ml vials for other patients so why not just give "1 vial" or 200 mg to most patients and keep it simple? As long as the patient weighs more than 50kg the 200 mg vial won't result in more than 4 mg/kg of sugammadex.
Of course, if you wish to keep it scientific I understand using actual dosing ranges and respect that approach.
 
$12 more for sugga over neostig/glyco for us. We're working on pharmacy to give us their blessing to use sugga for routine reversals.
 
sevoflurane said:
So far very impressed with this stuff.
Amazing how quickly you can go from 1/4 to 4/4.

Ear case. 45 minutes. 40 mg of Roc. SV mode at end of the case with 1/4 and 70 cc TV.
200mg of Sugamma-f'n-dex. 30 seconds later 650 TV's. Impressive.

Is everyone following 4mg/kg dosing?


IMG_9417_zpsrlatrsnm.jpg
Click to expand...

This drug pisses me off. It took me years to finally learn not to get burned with too much Roc, now it doesn't even matter.
 
caligas said:
This drug pisses me off. It took me years to finally learn not to get burned with too much Roc, now it doesn't even matter.
Click to expand...

I bet that over time there will be shortages. And there are a handful of indications for the use of gly/neo over sugammadex.
 
sevoflurane said:
I bet that over time there will be shortages. And there are a handful of indications for the use of gly/neo over sugammadex.
Click to expand...

... or rather relative contraindications for the use of suggamadex.
 
I did a rotation in Utah with a pp guy in April, just as they got it added to the formulary.

We used it on 15+ patients with excellent results. The doc I was working with was actually under dosing most of the time and still having what appeared to be complete reversal. If the patient was 70-100kg, he might give half the vial (so about 1-1.5 mg/kg). We were always willing to give more if needed. It was never needed. Saved the other half of the vial for the next patient needing reversal. I think we only did the 2mg/kg on one patient.

As with others, we'd go from 0-1/4 to 4/4 in 30 seconds at most.

He said it was costing them less than neo/glyco combo at their facility, even if he had been following the recommended dose.
 
abolt18 said:
I did a rotation in Utah with a pp guy in April, just as they got it added to the formulary.

We used it on 15+ patients with excellent results. The doc I was working with was actually under dosing most of the time and still having what appeared to be complete reversal. If the patient was 70-100kg, he might give half the vial (so about 1-1.5 mg/kg). We were always willing to give more if needed. It was never needed. Saved the other half of the vial for the next patient needing reversal. I think we only did the 2mg/kg on one patient.

As with others, we'd go from 0-1/4 to 4/4 in 30 seconds at most.

He said it was costing them less than neo/glyco combo at their facility, even if he had been following the recommended dose.
Click to expand...

One could probably just buy the 500 mg bottles for slightly more if they were going to be using on multiple people.


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Heard suggamadex may render BCP's ineffective. Could be a problem in a large patient population.
 
ZzzPlz said:
Heard suggamadex may render BCP's ineffective. Could be a problem in a large patient population.
Click to expand...


Yes - we were told when we use it on a patient who is taking OCPs that we must give them a letter to use alternative forms of contraception for a week.
 
Package insert says to take additional dose as if you had missed the days dose.


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I've used it several times now. Absolutely love it. It's saved me once from a reintubation in the PACU and last night I was able to use it to reverse roc after an RSI in a MH patient.
 
I agree with others, this stuff works and it works great! I had a case last Sunday where I was called to the room, the CRNA had the mask smashed on the patient's face, the patient was flopping and flailing around. I was told she had 2/4 twitches back (reversed with neo), good Vt, but she was just "anxious." I immediately went to our pharmacy which is by the ORs, got a bottle, gave 2 mg/kg, and within 15 seconds, the patient was taking full Vt and we wheeled her to PACU. No doubt in my mind I would've re-intubated, extubated in PACU probably an hour later, and sent to the ICU for overnight obs.
 
I was hoping this thread would spin into s/e and cautions as I'm fairly confident this drug is going to take off here in the US and will become part of our routine practice.

As far as I know these are the major ones:

Bradycardia- including cardiac arrest
Allergic reactions- including severe anaphalaxis
Abonormal coagulation- increase in pt/ptt levels up to 25% in ortho patients.
Caution in renal impariment and avoid in CRF.
OCPs- seen analagous to missing a daily dose. Should we avoid it in women who have CRD (low GFRs) and of child bearing age?
Recurarization?
I think there is also an interaction with some of the CCB? I've heard it can be used in treatment of CCB toxicity, ie verapamil. Could it cause post operative hypertension in patients taking CCB's by permenantly binding to circulating CCB's?
 
In Japan five advanced bradycardias and seven cardiac arrests have been reported as side effects of Sugammadex. However, in our hospital we experienced one case of sugammadex-induced severe bradycardia in 4108 cases of sugammadex used from August 2010 to February 2014. This would indicate a higher possibility of bradycardia than previously reported. It seems that the appearance of side effects such as bradycardia occur 3 to 5 minutes after sugammadex injection. We have to observe patients carefully for 5 to 10 minutes after administration of sugammadex.


http://www.asaabstracts.com/strands...67CE8DAE3584153?year=2014&index=7&absnum=3122
 
Sugammadex-induced anaphylaxis typically presents when the patient is already extubated and is being transferred to the hospital bed, PACU, ICU, etc. [3], time points when the patient is typically less monitored. Therefore, rapid diagnosis and appropriate treatment of anaphylaxis, including administration of adrenaline, oxygen, and large volumes of crystalloids, are required. In the current report, patients 1 and 2 were treated with 0.1 and 0.5 mg adrenaline IV, respectively. Although the maximum intravenous bolus dose of adrenaline recommended by recent guidelines for anaphylaxis during anesthesia is variable [17, 19], the IV bolus dose of 0.5 mg adrenaline administered to case 2 appears to be a larger dose than that recommended by guidelines.


None of our patients had prior exposure to sugammadex. Cyclodextrins, one of the components of sugammadex preparations, are present in various foods, which may partly explain the cross-reaction with sugammadex.

http://bmcanesthesiol.biomedcentral.com/articles/10.1186/1471-2253-14-92
 
Regarding the additional information on sugammadex and hemostasis, only high doses (4 and 16 mg/kg) prolonged the aPTT and PT by 17-22%.



These limited mean aPTT and PT(INR) prolongations were of short duration (≤ 30 minutes)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4318859/
 
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