Sugammadex and Asystole

[deleted162650]

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Partner's case:

15yo healthy 65kg kid for short outpatient procedure at ASC. 30 of roc on induction. 20ish mins later operation done. Reversed w/ 150mg Sug . . . flat EKG. Pulse-ox agonal. EtCO2 disappearing. Surgeon called back into the room to start CPR while another partner comes in to help. 30s of chest compression + some epi (maybe 500ish mcg) and rhythm comes back. Accelerated junctional for while before making it back to sinus. Kept kid intubated and took him up to the hospital ICU or further monitoring. No further events and uneventful extubation later on.

Anybody hear of/experience anything similar?

 

[okayplayer]

Partner's case:

15yo healthy 65kg kid for short outpatient procedure at ASC. 30 of roc on induction. 20ish mins later operation done. Reversed w/ 150mg Sug . . . flat EKG. Pulse-ox agonal. EtCO2 disappearing. Surgeon called back into the room to start CPR while another partner comes in to help. 30s of chest compression + some epi (maybe 500ish mcg) and rhythm comes back. Accelerated junctional for while before making it back to sinus. Kept kid intubated and took him up to the hospital ICU or further monitoring. No further events and uneventful extubation later on.

Anybody hear of/experience anything similar?

Drug error?

 

[deleted59964]

No - I’ve used suga quite a bit for 6 years now. Nor have I heard of any

 

[deleted59964]

Drug error?

Not to be casting aspersions, but that has to be seriously considered

 

[deleted162650]

Drug error?

I had that thought too, but this guy is pretty anal about his set-up (rumor has it he even combs the tassels on his rugs at home).

There are case reports of marked bradycardia/asystole from sugammadex.

 

[vector2]

Asystole and symptomatic bradycardia are rare but known risks with sug....

 

[okayplayer]

I had that thought too, but this guy is pretty anal about his set-up (rumor has it he even combs the tassels on his rugs at home).

There are case reports of marked bradycardia/asystole from sugammadex.

That’s a scary side effect dude.

 

[MirrorTodd]

For real. More likely in kids?

 

[DrOwnage]

Are you sure there weren't another other signs i.e. anaphylaxis leading to the code?

 

[fakin' the funk]

Drug error?

This is the most likely explanation, or, unrecognized hypoxemia --> bradyasystole.

How do you have your sugammadex vials? 200/2ml? Possible partner actually gave 1.5ml adenosine.

 

[btbam]

Partner's case:

15yo healthy 65kg kid for short outpatient procedure at ASC. 30 of roc on induction. 20ish mins later operation done. Reversed w/ 150mg Sug . . . flat EKG. Pulse-ox agonal. EtCO2 disappearing. Surgeon called back into the room to start CPR while another partner comes in to help. 30s of chest compression + some epi (maybe 500ish mcg) and rhythm comes back. Accelerated junctional for while before making it back to sinus. Kept kid intubated and took him up to the hospital ICU or further monitoring. No further events and uneventful extubation later on.

Anybody hear of/experience anything similar?

Interesting. That’s a pretty small dose too. Wasn’t like giving 16 per.

 

[dhb]

This is the most likely explanation, or, unrecognized hypoxemia --> bradyasystole.

How do you have your sugammadex vials? 200/2ml? Possible partner actually gave 1.5ml adenosine.

You don't need 0.5mg of epi to come back from adenosine.

 

[CopaceticOne]

Anybody hear of/experience anything similar?

Yes, I’ve personally witnessed this reaction to sugammadex in an adult. It wasn’t a huge or arbitrary dose. No prior exposure either.

 

[deleted171991]

Partner's case:

15yo healthy 65kg kid for short outpatient procedure at ASC. 30 of roc on induction. 20ish mins later operation done. Reversed w/ 150mg Sug . . . flat EKG. Pulse-ox agonal. EtCO2 disappearing. Surgeon called back into the room to start CPR while another partner comes in to help. 30s of chest compression + some epi (maybe 500ish mcg) and rhythm comes back. Accelerated junctional for while before making it back to sinus. Kept kid intubated and took him up to the hospital ICU or further monitoring. No further events and uneventful extubation later on.

Anybody hear of/experience anything similar?

Yes. Bradycardia is one of the side effects of sugammadex. One of my colleagues has reportedly experienced it, but not to the level of asystole. I tend to give about 50 mg at first, wait a minute or two for the bad stuff, then give the rest.

 

[Southpaw]

Was the patient still intubated? This could be just a super rare side effect, but all the untoward reactions to suggamadex that I’ve seen where in patients where it was given w little to no gas on board with the tube still in.

 

[kmurp]

We haven’t seen asystole but our group early on noticed the sometimes extreme bradycardia with this drug. I think most of us give it slowly in divided doses in the hope that this will help avoid this side effect.

 

[deleted162650]

This is the most likely explanation, or, unrecognized hypoxemia --> bradyasystole.

How do you have your sugammadex vials? 200/2ml? Possible partner actually gave 1.5ml adenosine.

No adenosine in our carts at the ASC.

 

[deleted875186]

Agreed, I have seen bradycardia into the 40’s in adults from suggamadex, I am not that surprised you could get asystole from it in a kid. We have started to use neostigmine most of the time as a cost savings measure.

 

[deleted162650]

Was the patient still intubated? This could be just a super rare side effect, but all the untoward reactions to suggamadex that I’ve seen where in patients where it was given w little to no gas on board with the tube still in.

Ya still tubed. I though about rapid reversal —> cough/buck —> vagal but I’m told that wasn’t the case.

 

[deleted171991]

Agreed, I have seen bradycardia into the 40’s in adults from suggamadex, I am not that surprised you could get asystole from it in a kid. We have started to use neostigmine most of the time as a cost savings measure.

There is no cost saving with neo + glyco versus sugammadex.

 

[Southpaw]

Ya still tubed. I though about rapid reversal —> cough/buck —> vagal but I’m told that wasn’t the case.

I guess I could do some Blade-style googlin’ but it’s saturday and I’m just not up for it. Can anyone think of any other mechanism for brady leading to asystole in otherwise healthy young folks?

FYI I’m a big believer in the sugga but i think it should be given early in fully anesthetized folks, or if given late, after the tube is out.

 

[deleted59964]

This is the most likely explanation, or, unrecognized hypoxemia --> bradyasystole.

How do you have your sugammadex vials? 200/2ml? Possible partner actually gave 1.5ml adenosine.

Or straight neostigmine

 

[San Marzano]

I guess I could do some Blade-style googlin’ but it’s saturday and I’m just not up for it. Can anyone think of any other mechanism for brady leading to asystole in otherwise healthy young folks?

FYI I’m a big believer in the sugga but i think it should be given early in fully anesthetized folks, or if given late, after the tube is out.

I had a healthy young dude can't remember exact age but either late teens or early 20's who went 60 to zero due to surgical stimulation during an inguinal hernia repair. I was a very new CA1 and it scared the **** out of me.

 

[koan]

i think it should be given early in fully anesthetized folks, or if given late, after the tube is out.

What's your reasoning for above?

Anaphylaxis was 0.3% in one trial (1/299 healthy subjects) but can't find incidence of bradycardia -> asystole, Merck literature just says it "has been observed" and should be treated with atropine. Strange bc rocuronium shouldn't be interacting with M2 receptors.

 

[Twiggidy]

Partner's case:

15yo healthy 65kg kid for short outpatient procedure at ASC. 30 of roc on induction. 20ish mins later operation done. Reversed w/ 150mg Sug . . . flat EKG. Pulse-ox agonal. EtCO2 disappearing. Surgeon called back into the room to start CPR while another partner comes in to help. 30s of chest compression + some epi (maybe 500ish mcg) and rhythm comes back. Accelerated junctional for while before making it back to sinus. Kept kid intubated and took him up to the hospital ICU or further monitoring. No further events and uneventful extubation later on.

Anybody hear of/experience anything similar?

Completely derailing question.......but what was the case? Edit: Oh, and were there any contraindications to Sux?

 

[Southpaw]

What's your reasoning for above?

Anaphylaxis was 0.3% in one trial (1/299 healthy subjects) but can't find incidence of bradycardia -> asystole, Merck literature just says it "has been observed" and should be treated with atropine. Strange bc rocuronium shouldn't be interacting with M2 receptors.

I’ve had partners describe some bad cases of bronchospasm post-suggamadex in lightly anesthetized but still intubated patients. Suggamadex reversal is nothing like neo/glyco reversal. It’s fast and complete, total reversal. I think getting the tube out early helps avoid some of those issues (not necessarily asystole, hard to pinpoint that one as no one has yet given a possible mechanism).

 

[sbhfl]

Completely derailing question.......but what was the case? Edit: Oh, and were there any contraindications to Sux?

You mean like postop myalgias and potential phosphodiesterase deficiency? Histamine release and bronchospasm? Sux is good for rapid intubating conditions in non-burn non-stroke non-MH non-small peds cases when also assuming the patient is allergic to rocuronium.

 

[deleted162650]

Completely derailing question.......but what was the case? Edit: Oh, and were there any contraindications to Sux?

Tonsils. No contraindications to sux. Just not wanting myalgias.

 

[shepardsun]

There is no cost saving with neo + glyco versus suggamadex.

Out of curiosity, do you have a source for this? Most of the old timers at my institution will harp on the frequency with which we use it with mumbled complaints about cost relative to neo + glyco. I know every hospital will pay a little bit different amounts for their meds but it'd be interesting to have an article or two to show them. I've seen a few that make an argument for factoring in a decrease in respiratory events in the PACU and floor compared to neo + glyco as being a "total cost" savings thing.

 

[ZzzPlz]

There is no cost saving with neo + glyco versus suggamadex.

Out of curiosity, do you have a source for this? Most of the old timers at my institution will harp on the frequency with which we use it with mumbled complaints about cost relative to neo + glyco. I know every hospital will pay a little bit different amounts for their meds but it'd be interesting to have an article or two to show them. I've seen a few that make an argument for factoring in a decrease in respiratory events in the PACU and floor compared to neo + glyco as being a "total cost" savings thing.

True they are similar in a hospital setting. Not true at our same day surgery center, where suggama costs much more than glyco/neo.

 

[Twiggidy]

You mean like postop myalgias and potential phosphodiesterase deficiency? Histamine release and bronchospasm? Sux is good for rapid intubating conditions in non-burn non-stroke non-MH non-small peds cases when also assuming the patient is allergic to rocuronium.

That’s for the CME.....do it get like 0.3 credits or something for that?

 

[KaoticMessiah]

I had a patient become asystolic around 1 minute after reversal with sugammadex, but he was also coughing vigorously at the same time. I chalked it up to a potent vagal tone + sugammadex, but maybe it was solely from the sugammadex now that I think about it.
He did fine, only needed one round of chest compressions and 100 mcg epinephrine.
Got a Cardiology consult post-op (I figured anyone who arrests has earned at least a look-over by a Cardiologist), but workup was wholly negative and he went to the floor after PACU.

 

[Twiggidy]

Tonsils. No contraindications to sux. Just not wanting myalgias.

Cool. Was mainly interested for my personal case files

 

[sbhfl]

That’s for the CME.....do it get like 0.3 credits or something for that?

I give grammar lessons too 🙂.

 

[deleted171991]

Out of curiosity, do you have a source for this? Most of the old timers at my institution will harp on the frequency with which we use it with mumbled complaints about cost relative to neo + glyco. I know every hospital will pay a little bit different amounts for their meds but it'd be interesting to have an article or two to show them. I've seen a few that make an argument for factoring in a decrease in respiratory events in the PACU and floor compared to neo + glyco as being a "total cost" savings thing.

Ask your pharmacy how much each costs them.

 

[Twiggidy]

As I’m sure most of us have already Googled, there are a handful of case reports of cardiac arrest after sugammadex

 

[Twiggidy]

Ask your pharmacy how much each costs them.

I always figure if something isn’t readily available in my cart it must be too expensive. You have to jump through a few hoops to get it at my shop.

 

[deleted171991]

I always figure if something isn’t readily available in my cart it must be too expensive. You have to jump through a few hoops to get it at my shop.

Yeah, but many bean counting analphabets can't compare the cost of 1 vial of 200 mg of suggamadex with 1 vial of 5 mg neostigmine plus 4-5 vials of 0.2 mg glycopyrrolate. All they see is that neo is cheaper than sugga.

 

[Twiggidy]

I give grammar lessons too 🙂.

Fat fingers, iPhones and autocorrect.....what can I do?

 

[Twiggidy]

Yeah, but many bean counting analphabets can't compare the cost of 1 vial of 200 mg of suggamadex with 1 vial of 5 mg neostigmine plus 4-5 vials of 0.2 mg glycopyrrolate. All they see is that neo is cheaper than sugga.

I agree. Don’t get my started on my hospital suits.

 

[narcusprince]

Why did the crna give 150mg? Something smells drug error trying to clean up ish. In my practice either patients get one ampule or two ampules based on body weight. I have seen some bradycardia but never asystole.

 

[deleted162650]

Why did the crna give 150mg? Something smells drug error trying to clean up ish. In my practice either patients get one ampule or two ampules based on body weight. I have seen some bradycardia but never asystole.

No nurses here. Solid MD doing the case. I think most of us have settled on about 2/kg hence the 150mg dose.

 

[facted]

There is no cost saving with neo + glyco versus suggamadex.

Now there is. Neostigmine dropped in price significantly recently, at least in our system.

 

[narcusprince]

I have given sugg at 4mg/kg and have not seen increased bradycardia with higher doses. Why waste the additional sugg? My opinion the bradycardia is not dose dependant between the 2-4mg/kg dosing.

 

[Twiggidy]

No nurses here. Solid MD doing the case. I think most of us have settled on about 2/kg hence the 150mg dose.

I think it's going to have to be one of those thing that people who use sugammedex just have to keep in the back of their heads. I've only been seeing case reports and I'm not sure anyone knows the mechanism by which it happens.

 

[T-burglar]

This is an interesting thread.

I've given thousands of doses, I always give the whole 200 mg amp, and the vat majority of the time I'm giving it the residual NMB before reversing is minimal

and I've never even seen bradycardia, let alone PEA or asystole. I also do all my own cases and never supervise a nurse, for whatever that's worth.

 

[Southpaw]

Out of curiosity, do you have a source for this? Most of the old timers at my institution will harp on the frequency with which we use it with mumbled complaints about cost relative to neo + glyco. I know every hospital will pay a little bit different amounts for their meds but it'd be interesting to have an article or two to show them. I've seen a few that make an argument for factoring in a decrease in respiratory events in the PACU and floor compared to neo + glyco as being a "total cost" savings thing.

No articles but my pharmacy said hospital cost for 5cc vial Neo + 2 vials 1cc glyco = $70 whole 1 vial 2cc sugga = $80.

I’ve believe there’s less PONV, shorter PACU, better wake ups w sugga making it worth the cost. If you’re using the 5cc vial it’s most likely bc your patient is so big, so while cost is greater I still think it’s worth it.

Your gray hairs are being contrary bc they all are, about everything.

 

[narcusprince]

I wonder if the bradycardia may be related to certain hereditary backgrounds. Someone who practices in the northeast may see more then those that pracice in the South. We all know the hereditary link with MH and pseudocholinesterase deficiency. I practice in a environment where my patients have heterogeneous backgrounds, military. Good study....

 

[Ezekiel2517]

I use sugga all the time. Never even seen bradycardia. Most likely not the cause in this case. Hard for any anesthesiologist who wasn't doing the case to make conclusions here. So many things are going on during emergence/extubation, especially in a quick case like this. There are case reports of cardiac arrest after administration of thousands of different drugs, look them up and you'll see. One can argue that badness is much more likely to happen after giving Zofran than sugga, bc of the effect on QT

 

[San Marzano]

No articles but my pharmacy said hospital cost for 5cc vial Neo + 2 vials 1cc glyco = $70 whole 1 vial 2cc sugga = $80.

I’ve believe there’s less PONV, shorter PACU, better wake ups w sugga making it worth the cost. If you’re using the 5cc vial it’s most likely bc your patient is so big, so while cost is greater I still think it’s worth it.

Your gray hairs are being contrary bc they all are, about everything.

All I have is anecdotal experience but I spent three years of residency constantly checking twitches and worrying about reversal towards the end of lots of cases and even after giving an appropriate dose of neo/glyco after four twitches were back I would still see some floppy looking people waking up. Now that I'm in a hospital with sugammadex my patients are popping awake like nobody's business. The pharmacology just makes so much more sense and it's a more appropriate drug for neuromuscular blockade reversal in my little opinion. One day anesthesiologists may look back on neo/glyco reversal the same way my generation views halothane or barbiturates I think.