Sugamma-f'n-dex

[BLADEMDA]

Use of sugammadex is increasing. It is known to encapsulate steroidal non-depolarizing muscle relaxants used for anesthesia in order to reverse the effect of these drugs [23,25].Although it encapsulates verapamil 120–700 times less than rocuronium, its beneficial effects have been shown for verapamil toxicity [18,25].

Ozbilgin et al. [18] reported that sugammadex, a modified gamma cyclodextrin, at 16 mg/kg dose, prolonged survival and increased LD in rats when administered for verapamil toxicity, similar to intralipid and SBE-CD


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4809387/

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[BLADEMDA]

Hormonal contraceptives: The interaction between 4 mg/kg sugammadex and a progestogen was predicted to lead to a decrease in progestogen exposure (34% of AUC) similar to the decrease seen when a daily dose of an oral contraceptive is taken 12 hours too late, which might lead to a reduction in effectiveness. For oestrogens, the effect is expected to be lower. Therefore the administration of a bolus dose of sugammadex is considered to be equivalent to one missed daily dose of oral contraceptive steroids (either combined or progestogen only). If sugammadex is administered at the same day as an oral contraceptive is taken reference is made to missed dose advice in the package leaflet of the oral contraceptive. In the case of non-oral hormonal contraceptives, the patient must use an additional non hormonal contraceptive method for the next 7 days and refer to the advice in the package leaflet of the product.

 

[pjl]

Recurarization after sugammadex reversal in an obese patient.

http://www.ncbi.nlm.nih.gov/pubmed/21751072

This is the only one that surprises me, based on mechanism of action.


Look at the drug data for anaphylaxis, it is really common at 16 mg/kg, almost nonexistent at 2 mg/kg.


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[sethco]

Recurarization after sugammadex reversal in an obese patient.

http://www.ncbi.nlm.nih.gov/pubmed/21751072

Do they recommend dosing by actual or ideal body weight? That case report seeemed like they underdosed. Also, 170 mg Rocuronium for a <3 hour procedure is a little much. Makes me curious whether they had two twitches in the first place. Maybe should have dosed it at 4 mg/kg?

 

[sevoflurane]

Do they recommend dosing by actual or ideal body weight? That case report seeemed like they underdosed. Also, 170 mg Rocuronium for a <3 hour procedure is a little much. Makes me curious whether they had two twitches in the first place. Maybe should have dosed it at 4 mg/kg?

I'm not sure how they are dosing as it's not really mentioned. They do mention 2/4 twitches? Truth? Not sure. However, my experience is that roc is less predictable than vec. That being said, suggamadex has a large volume of distribution. I merely bring it up as something to think about with a new player. If you have OCPs, CCB and other potential substrates that bind suggamadex on board... then what is the effective dose. Does obesity play a role? Queations. My N is < 15

This drug has caught our eye.

I think questioning its r and b under honest diacussions is a good way to truly understanding this new player.

 

[pjl]

Dosing based on actual body weight.


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[sigrhoillusion]

I'm not sure how they are dosing as it's not really mentioned. They do mention 2/4 twitches? Truth? Not sure. However, my experience is that roc is less predictable than vec. That being said, suggamadex has a large volume of distribution. I merely bring it up as something to think about with a new player. If you have OCPs, CCB and other potential substrates that bind suggamadex on board... then what is the effective dose. Does obesity play a role? Queations. My N is < 15

This drug has caught our eye.

I think questioning its r and b under honest diacussions is a good way to truly understanding this new player.

Just started at working my first gig at an academic center. Spoke to a few staff who said that we don't have suggamadex... yet. But supposedly they just had an informational about it with a rep (probably a hot blond...) a week or so before I started, so there's a chance we could start stocking it soon. Would love to have it available since I'm mostly supervising and some trainees don't realize you're allowed to look over the drapes or communicate with the surgeon to know where they are in the operation...

Want to at least try it a few times and see it's magic for my self. Don't expect it to take over my practice, but if what a lot of people are saying is true about teh costs vs. glcyo/neostig then could see it taking over. But once it starts taking off, I can just see the "shortages" and high costs of neostig suddenly disappearing. The odd thing is that where I just finished my fellowship, neostig was like $60/vial for the 10cc multidose, which is what I've been hearing is aroundn the norm. But supposedly at my new job, they get pre-made syringes which supposedly cost only $5 each. Which I don't know how that's possible... Unless pharmacy is getting like BAGS of neostig and dividing them into the syringes under a hood. But if it's true, then the Bridion invasion might take a little while longer.

 

[BLADEMDA]

I'm not sure how they are dosing as it's not really mentioned. They do mention 2/4 twitches? Truth? Not sure. However, my experience is that roc is less predictable than vec. That being said, suggamadex has a large volume of distribution. I merely bring it up as something to think about with a new player. If you have OCPs, CCB and other potential substrates that bind suggamadex on board... then what is the effective dose. Does obesity play a role? Queations. My N is < 15

This drug has caught our eye.

I think questioning its r and b under honest diacussions is a good way to truly understanding this new player.

You are over-thinking this drug. If you keep the dosage low (2 mg/kg actual body weight) the interaction is MINIMAL with CCBs and OCPs. In addition, the bradycardia side-effect is uncommon at the low dosage range.

As you increase the dosage the interaction with OCPs and CCBs becomes more significant. From a legal standpoint the company must make the statement about the interaction with OCPs but at the the 2 mg/kg dosage It probably isn't even like missing one birth control (more like 1/2 a pill).

 

[sevoflurane]

You are over-thinking this drug. If you keep the dosage low (2 mg/kg actual body weight) the interaction is MINIMAL with CCBs and OCPs. In addition, the bradycardia side-effect is uncommon at the low dosage range.

As you increase the dosage the interaction with OCPs and CCBs becomes more significant. From a legal standpoint the company must make the statement about the interaction with OCPs but at the the 2 mg/kg dosage It probably isn't even like missing one birth control (more like 1/2 a pill).

Just cautious as I would be with any new drug I plan to use. FDA didn't approve it until now for a reason. Mainly for concerns of anaphylaxis, hypersensitivity and coagulation issues. These do seem to be rare events.

History of Suggamadex approval in the USA:

http://www.apsf.org/newsletters/html/2016/February/06_Sugammadex.htm

 

[Noyac]

So I used it twice today.
I'm sold!

Now I need to work on the art of using it. Both actually bucked a little on the tube. I haven't had a pt buck on the tube in months, maybe even a year or more.
Both also had been topicalization with an LTA.
Maybe I'll give 50mcg of fentanyl with the sugg.
Maybe 100mg of lido.

Stay tuned.

 

[BLADEMDA]

So I used it twice today.
I'm sold!

Now I need to work on the art of using it. Both actually bucked a little on the tube. I haven't had a pt buck on the tube in months, maybe even a year or more.
Both also had been topicalization with an LTA.
Maybe I'll give 50mcg of fentanyl with the sugg.
Maybe 100mg of lido.

Stay tuned.

Unlike Neostigmine which can take 5-9 minutes to fully kick in Sugammadex works in 30 seconds. This means don't give it until you are ready to extubate the patient. IMHO of tens of thousands of cases nothing works better than a little propofol iv to prevent bucking at the end of the case. Propofol in the 0.3-0.5 mg/kg IV range works wonders for a smooth, uneventful extubation. Of course, another great technique is to get the patient spontaneously breathing at the end of the case then titrate in your narcotics based on respiratory rate for a smooth wake-up.

I'm sure, at this point in your career, you are adept at all these tricks of the trade.

 

[sevoflurane]

So I used it twice today.
I'm sold!

Now I need to work on the art of using it. Both actually bucked a little on the tube. I haven't had a pt buck on the tube in months, maybe even a year or more.
Both also had been topicalization with an LTA.
Maybe I'll give 50mcg of fentanyl with the sugg.
Maybe 100mg of lido.

Stay tuned.

Shoot bro... I haven't had a patient buck on the tube since before I was born!
Glad you're digging the SUGGA.

 

[DrN2O]

It just encourages lazy anesthesia. Brand new CA1s have used it more than I have. I already get pages like "Dr X requested 0 post-tetanic. Gave 30 more roc. Will order Sug." I can't really argue with better drugs. First US. Then glide. Now this. Soon robots WILL be able to do our jobs.

 

[BLADEMDA]

It just encourages lazy anesthesia. Brand new CA1s have used it more than I have. I already get pages like "Dr X requested 0 post-tetanic. Gave 30 more roc. Will order Sug." I can't really argue with better drugs. First US. Then glide. Now this. Soon robots WILL be able to do our jobs.

Or nurses.

 

[caligas]

It just encourages lazy anesthesia. Brand new CA1s have used it more than I have. I already get pages like "Dr X requested 0 post-tetanic. Gave 30 more roc. Will order Sug." I can't really argue with better drugs. First US. Then glide. Now this. Soon robots WILL be able to do our jobs.

Im sure surgical conditions deteriorate greatly with those pesky post tetanic twitches.

 

[Noyac]

Unlike Neostigmine which can take 5-9 minutes to fully kick in Sugammadex works in 30 seconds. This means don't give it until you are ready to extubate the patient. IMHO of tens of thousands of cases nothing works better than a little propofol iv to prevent bucking at the end of the case. Propofol in the 0.3-0.5 mg/kg IV range works wonders for a smooth, uneventful extubation. Of course, another great technique is to get the patient spontaneously breathing at the end of the case then titrate in your narcotics based on respiratory rate for a smooth wake-up.

I'm sure, at this point in your career, you are adept at all these tricks of the trade.

Yep that's my technique as well. But with this drug, you can't as easily get the pt breathing at the end of the case or else you wouldn't need the drug and if you do give it they go straight to deep breaths. So I'm with you on this one. Give some propofol why you give the sug. Or maybe some fentanyl. I'll play around with it some more. M

 

[dhb]

I'm sure it's a great drug and i would have no problem using it if the price was on par with neo, but here neo is 4€ vs 82€ for bridion.
Would you still use it if the price difference was so big?

 

[BLADEMDA]

I'm sure it's a great drug and i would have no problem using it if the price was on par with neo, but here neo is 4€ vs 82€ for bridion.
Would you still use it if the price difference was so big?

You should be starting a business and selling that Neostigmine in the USA. But, to answer your question I would limit the use of Sugammadex if it costs double or more compared to Neostigmine/Glyco. I would still have it on formularly but limit its use to 1-2 vials per day for the operating room suite.

 

[deleted162650]

Im sure surgical conditions deteriorate greatly with those pesky post tetanic twitches.

I like you, you're funny. You ever want a job back in CA you let me know.

 

[caligas]

I like you, you're funny. You ever want a job back in CA you let me know.

Thanks!!!

My wife and I only lament leaving Cali about twice a day. Really miss it. But the parents and In laws are all here and I unfortunately surrendered my Cali license.

 

[btbam]

Im sure surgical conditions deteriorate greatly with those pesky post tetanic twitches.

Surgeon: "They still feel tight"

Me: *gun to temple behind the drapes*

 

[Noyac]

Surgeon: "They still feel tight"

Me: *gun to temple behind the drapes*

It doesn't have to be so painful. Just tell them "ok, let me give more." Rustle around a bit and then ask them," how's that?" Then try not to lose your **** when they say, " that's so much better, thanks."

 

[deleted162650]

It doesn't have to be so painful. Just tell them "ok, let me give more." Rustle around a bit and then ask them," how's that?" Then try not to lose your **** when they say, " that's so much better, thanks."

Have you ever called em out after doing that trick just to make em realize how fulla **** they are??

I would love to see the look on their face.

 

[ZzzPlz]

Have you ever called em out after doing that trick just to make em realize how fulla **** they are??

I would love to see the look on their face.

No way that would end well

 

[deleted162650]

I don't think it would be terrible if you were good buddies with the surgeon.

 

[ZzzPlz]

If I was good buddies with the surgeon he wouldn't say that

 

[Noyac]

Have you ever called em out after doing that trick just to make em realize how fulla **** they are??

I would love to see the look on their face.

Nah. That would just take that tactic off the table for the future.

 

[Noyac]

We are all just having fun with this. But in reality you need to understand the situation.
When the surgeon asks for more relaxation and your pt is 1 twitch or less this just means that your surgeon is struggling. This is not a time to tell him or her that that is all you get cuz the pt is plenty relaxed. It's a surgeon's nature to look for others to blame for their troubles much of the time. The good ones will ask if the pt is relaxed well and the poorer ones will say that they need more relaxation. All you need to do is understand were they are coming from at that moment and accommodate them in some form. Maybe you just turn up the gas. Or you can fake it like I described but I don't recommend that, I was really just having fun with the topic.
This is some of the art of anesthesia. Taking care of the pt is something we are all trained to do. Unfortunately, the pt is not the only person in the room we actually need to take care of.
You can disagree with this or even fight this. But in the long run, you and everyone around you in that room will benefit if you massage the situation and "help" the surgeon get through their struggles. Not to mention how this will begin to endear you among the staff and surgeons.

 

[deleted162650]

We are all just having fun with this. But in reality you need to understand the situation.
When the surgeon asks for more relaxation and your pt is 1 twitch or less this just means that your surgeon is struggling. This is not a time to tell him or her that that is all you get cuz the pt is plenty relaxed. It's a surgeon's nature to look for others to blame for their troubles much of the time. The good ones will ask if the pt is relaxed well and the poorer ones will say that they need more relaxation. All you need to do is understand were they are coming from at that moment and accommodate them in some form. Maybe you just turn up the gas. Or you can fake it like I described but I don't recommend that, I was really just having fun with the topic.
This is some of the art of anesthesia. Taking care of the pt is something we are all trained to do. Unfortunately, the pt is not the only person in the room we actually need to take care of.
You can disagree with this or even fight this. But in the long run, you and everyone around you in that room will benefit if you massage the situation and "help" the surgeon get through their struggles. Not to mention how this will begin to endear you among the staff and surgeons.

EXCELLENT and very wise post. We need to remember that our pt is our pt, but the surgeon is our client. Our first duty is to keep the pt safe, but our second duty is to facilitate the surgical procedure. We are by definition a supporting role (albeit an indispensable one). If a surgeon wants more relaxation - oblige, even if it's with 1/10th of a cc. Limit your battles to things that actually matter and will affect pt care or significantly monkey with your anesthetic. Talk to your surgeons. Make them laugh. Then sit down on SDN and tell us how stupid they are.

Still though, I hear the voice of one of my old attendings say "Good surgeons don't need paralysis, and bad surgeons don't deserve it"

 

[Noyac]

.
Still though, I hear the voice of one of my old attendings say "Good surgeons don't need paralysis, and bad surgeons don't deserve it"

That's a new twist on the old saying, " good surgeons deserve good anesthesia, bad surgeons need it."

Request:
If any of you have a copy or can get a copy of the form letter you hand out to women of child baring age after they receive Sugammadex please send it to me.
I just thought of this, is there one on the Sugammadex website?

 

[ZzzPlz]

You would give everyone a form letter? Why not just give them another pill in the recovery room? otherwise they'll be off a day

 

[deleted162650]

Just used it for the first time. It's magical.

 

[Sonny Crocket]

EXCELLENT and very wise post. We need to remember that our pt is our pt, but the surgeon is our client. Our first duty is to keep the pt safe, but our second duty is to facilitate the surgical procedure. We are by definition a supporting role (albeit an indispensable one). If a surgeon wants more relaxation - oblige, even if it's with 1/10th of a cc. Limit your battles to things that actually matter and will affect pt care or significantly monkey with your anesthetic. Talk to your surgeons. Make them laugh. Then sit down on SDN and tell us how stupid they are.

Still though, I hear the voice of one of my old attendings say "Good surgeons don't need paralysis, and bad surgeons don't deserve it"

We use TIVA on most cases here, in Scandinavia, that are GA. Patient almost never, needs more relaxation after intubation.

 

[deleted162650]

We use TIVA on most cases here, in Scandinavia, that are GA. Patient almost never, needs more relaxation after intubation.

I find it odd that you would need less muscle relaxant not using volatile which certainly cause some degree of muscle relaxation on their own. Perhaps Scandinavian surgeons are just not as big prima donnas as their American counterparts?

 

[kazuma]

I started using it on occasion over the last couple weeks and I agree it is magical. It's excellent for the few prima donnas I work with that demand 0/4 twitches when closing fascia. One thing I actually like about Neostigmine is the 5-10 min peak effect time and less chance for NPPE if they chomp down on the tube and you don't have a bite block in place. This stuff is so quick you better be prepared for hulk strength in 30 seconds, especially if it's a big/strong person that is prone to wake up thrashing. Better make sure you have an extra set of hands so they don't thrash off the table or injure themselves.

 

[Sonny Crocket]

I find it odd that you would need less muscle relaxant not using volatile which certainly cause some degree of muscle relaxation on their own. Perhaps Scandinavian surgeons are just not as big prima donnas as their American counterparts?

Both primadonna factor (did residency in the US) and the use of remi.

 

[deleted59964]

Recurarization after sugammadex reversal in an obese patient.

http://www.ncbi.nlm.nih.gov/pubmed/21751072

so - this is a case report of an obese patient who got respiratory failure after extubation and reversal with sugammadex.
I only read the abstract - but it doesn't say they re tested his TOF and he was re curarized - only that he got respiratory failure after reversal with sugammadex.

pfft -- bet it was obesity induced reduced FRC and a closing capacity issue.


I've reversed hundreds of patients with sugammadex -- it is the future

 

[drccw]

I have been waiting for this drug for a long time. I did residency at one of the clinical sites about 10 years ago and thought it was an awesome drug then... and it's an awesome drug now.

$90 a vial here at my hospital
Neostigme is $63 for a 10 mL multidose vial
Glyopyrollate is $6 for a 0.2 mg vial.

So the costs are pretty similar; unless you multidose the Neostigme.....

My typical dose is one vial....

drccw

 

[eventualeventer]

From the perspective of a patient/vet student geek, this is amazing stuff. As indicated on the left, I'm a medical tire fire, ASA 4. I have mitochondrial myopathy, chronic respiratory failure/non-invasive ventilation, OSA, and severe GI dysmotility to the point that I'm currently on TPN. Because of my history and the recommendations of my specialist, when I need a procedure, I get TIVA with ketamine and they keep me intubated in the ICU or PACU until I'm good and sober. After my last procedure, I woke up still paralyzed with 0/4 twitches. The experience of having that one drug pushed and being able to move and write a minute later was very interesting, to say the least.

 

[BLADEMDA]

I have been waiting for this drug for a long time. I did residency at one of the clinical sites about 10 years ago and thought it was an awesome drug then... and it's an awesome drug now.

$90 a vial here at my hospital
Neostigme is $63 for a 10 mL multidose vial
Glyopyrollate is $6 for a 0.2 mg vial.

So the costs are pretty similar; unless you multidose the Neostigme.....

My typical dose is one vial....

drccw

Sugammadex= $90.00

Typical full reversal dose Neo/Glyco= 81.00

 

[Noyac]

Is anyone aware of any good studies out as of yet showing improved turnover and less aspiration or reintubation after sugamedex?

I found this one: https://www.aci-llc.net/wp-content/uploads/2016/09/JC1609204.pdf

 

[sevoflurane]

Is anyone aware of any good studies out as of yet showing improved turnover and less aspiration or reintubation after sugamedex?

I found this one: https://www.aci-llc.net/wp-content/uploads/2016/09/JC1609204.pdf

I don't have any, but I use the sugar all the time. I feel like glyco/neo has now become the thiopental equivilant of induction agents.

 

[Noyac]

I don't have any, but I use the sugar all the time. I feel like glyco/neo has now become the thiopental equivilant of induction agents.

Agreed, we are still using it sparingly.
What are you telling or do for your fertile females before or after receiving sug?

 

[sevoflurane]

Agreed, we are still using it sparingly.
What are you telling or do for your fertile females before or after receiving sug?

I am a little more selective in it's use with females in this age population. When I use it I let them know that it's like missing an OCP for a day.... and to use secondary measures for a week.

 

[Ronin2258]

I don't have any, but I use the sugar all the time. I feel like glyco/neo has now become the thiopental equivilant of induction agents.

I encountered CA-1 residents today that had NO idea how to dose glyco/neo. I had to peel my eyeballs of the back of my glasses from that shock.

Sugammedex just came on formulary, and it will be a bit before we get it into the system (I sit on the pharmacy committee where I work...trust me, it was painful.)

It might be an easy sell for me when I try it.

I lecture to the residents neo isn't a true "reversal," i.e. a neutralizing agent.

It's a pre-amp for nerve signals. Alternatively, I call it declaring chemical warfare on our patients, and glycopyrolate is the counter agent.

I will have to keep both drug regimens in mind, as I expect sugammedex can get short, being a newer drug. I can see shortages being a problem as the drug gets used more.

 

[nimbus]

I encountered CA-1 residents today that had NO idea how to dose glyco/neo. I had to peel my eyeballs of the back of my glasses from that shock.

Sugammedex just came on formulary, and it will be a bit before we get it into the system (I sit on the pharmacy committee where I work...trust me, it was painful.)

It might be an easy sell for me when I try it.

I lecture to the residents neo isn't a true "reversal," i.e. a neutralizing agent.

It's a pre-amp for nerve signals. Alternatively, I call it declaring chemical warfare on our patients, and glycopyrolate is the counter agent.

I will have to keep both drug regimens in mind, as I expect sugammedex can get short, being a newer drug. I can see shortages being a problem as the drug gets used more.

There won't be a shortage at $90/vial. When it drops to $2 is when we'll see shortages.

 

[Consigliere]

Or nurses.

They already can and do do our jobs.