Sugammadex and Asystole

[Mman]

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.

Is it going to evolve into maybe we should give 0.2 mg of glycopyrrolate prior to the sugammadex? I mean the complication might be rare, but it is not exactly benign and perhaps we could minimize it even further.

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[jwk]

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.

Vagal reflexes can be incredibly impressive. They were fairly common in kids with inguinal hernia surgery when I was a student (PIA pedi surgeon pulling on the scrotum during emergence), and the oculo-cardiac reflex survives into old age as is frequently demonstrated by one of our vitreoretinal surgeons.

 

[abolt18]

Ask your pharmacy how much each costs them.

Glyco+neo = $54.50
Sugammadex = $88.73

These numbers are for a 100kg patient with 2/4 twitches to whom you give full reversal. i.e. 2 sticks of neo (ours are prepared in 3mL sticks) and 1 stick of glyco (prepared in 5ml, 1mg sticks). Or 1 200mg vial of sugammadex.

 

[nimbus]

Glyco+neo = $54.50
Sugammadex = $88.73

These numbers are for a 100kg patient with 2/4 twitches to whom you give full reversal. i.e. 2 sticks of neo (ours are prepared in 3mL sticks) and 1 stick of glyco (prepared in 5ml, 1mg sticks). Or 1 200mg vial of sugammadex.

Your pharmacy is smart to divide the neo. Around the time sugammadex was approved, the price of neostigmine went up. Where I work we are told....

Neostigmine 10mg vial + 2xglyco 0.4mg vials = $80

Sugammadex 200mg = $90

If you can split vials of either neostigmine or suga, then either can be much cheaper. I think suga 100mg is more than adequate in many cases.

 

[Orin]

Neat case reports
Profound Bradycardia and Cardiac Arrest After Sugammadex Administration in a Previously Healthy Patient: A Case Report. - PubMed - NCBI
Bradycardia in a Pediatric Heart Transplant Recipient: Is It the Sugammadex? - PubMed - NCBI

But this review of a bunch and recap is the best I think:
Sugammadex-induced bradycardia and asystole: how great is the risk? - PubMed - NCBI

 

[vector2]

Glyco+neo = $54.50
Sugammadex = $88.73

These numbers are for a 100kg patient with 2/4 twitches to whom you give full reversal. i.e. 2 sticks of neo (ours are prepared in 3mL sticks) and 1 stick of glyco (prepared in 5ml, 1mg sticks). Or 1 200mg vial of sugammadex.

I wish I could get the boneheads on the pharmacy committee to understand that the avoidance of residual NMB/pacu airway complications and the associated morbidity easily justifies the 30 bucks.

 

[Mman]

I wish I could get the boneheads on the pharmacy committee to understand that the avoidance of residual NMB/pacu airway complications and the associated morbidity easily justifies the 30 bucks.

ask them how much money antiemetics in PACU cost

 

[Daveizzy]

Shop in our area had a similar episode that resulted in intraoperative death, youngish, healthy-ish dude.

 

[narcotics999]

Shop in our area had a similar episode that resulted in intraoperative death, youngish, healthy-ish dude.

Scary.
I use it rarely. Definitely will be more watchful.
Thanks for the great posts.

 

[shepardsun]

What are people's practice with respect to timing of standard end-of-case, 2mg/kg sugammadex with >2 ToF twitches administration, on the spectrum from "instant fascia is closed" to "patient is awake and following commands one second before the tube comes out"?

 

[vector2]

With sug the reversal is so scary fast and complete I wait til there are just a couple skin stitches left or bandages are going on. Just make sure you have adequate opioid on board. I'm convinced that a bunch of our historical "smooth" wakeups were due to residual NMB judging by how pts nowadays are ready to jump off the table post-sug once the gas is down to 0.2 Mac.

 

[deleted9493]

When I first started using Sugammadex I had two neonates who both had significant bradycardia following administration. Administering conincident with the stimulation of emergence ever since, I have had no issues.

 

[Southpaw]

What are people's practice with respect to timing of standard end-of-case, 2mg/kg sugammadex with >2 ToF twitches administration, on the spectrum from "instant fascia is closed" to "patient is awake and following commands one second before the tube comes out"?

I tend to slowly dose (50mg increments) early in emergence with full MAC of gas on board and what I perceive to be adequate opioid on board.

If surgeon finishes quicker than I expect, I suction, extubate, and give 100-200 suggamadex.

I’ve witnessed partners giving suggamadex late in emergence (but still intubated) with very little gas and very little opioid on board. It’s not pretty.

 

[deleted162650]

The first couple times I used it, I Boulder the full dose and of course patients went from zero to bucking. Not smooth. Most of the time I still reverse late, but I give it very slowly prob 25mg at a time over 5mins or more and it’s just as smooth as neo/glyco.

 

[IlDestriero]

I tend to dose all my “iv push” drugs slowly. Maybe over a minute or two. Perhaps that helps an asystole event only be a clinically insignificant Brady, etc. I’m usually not doing much else and I never got into sudoku.

 

[abolt18]

With sug the reversal is so scary fast and complete I wait til there are just a couple skin stitches left or bandages are going on. Just make sure you have adequate opioid on board. I'm convinced that a bunch of our historical "smooth" wakeups were due to residual NMB judging by how pts nowadays are ready to jump off the table post-sug once the gas is down to 0.2 Mac.

Had an 83 yo patient today who had 2/4 twitches. Gave full dose reversal with Neo/glyco. 15 minutes later she's got next to no gas on, breathing on pressure support, floppy as a fish and unable to follow commands but will momentarily open eyes when you say her name.

Give 2mg/kg sugammadex and literally 30 seconds later she's almost jumping off the bed ready to rip out her tube.

 

[nimbus]

Because reversal is fast and complete and reliable with sugammadex, I’ve been experimenting with extubation first followed by reversal with sugammadex.

 

[San Marzano]

Because reversal is fast and complete and reliable with sugammadex, I’ve been experimenting with extubation first followed by reversal with sugammadex.

Do you mind sharing your thought process on this?

 

[shepardsun]

Had an 83 yo patient today who had 2/4 twitches. Gave full dose reversal with Neo/glyco. 15 minutes later she's got next to no gas on, breathing on pressure support, floppy as a fish and unable to follow commands but will momentarily open eyes when you say her name.

Give 2mg/kg sugammadex and literally 30 seconds later she's almost jumping off the bed ready to rip out her tube.

It's anecdotal stories like this coupled with my own experiences, combined with the fact that even if sugammadex is more expensive it's not by a whole bunch, that makes me wonder why I would ever reverse with neo/glyco again.

 

[abolt18]

It's anecdotal stories like this coupled with my own experiences, combined with the fact that even if sugammadex is more expensive it's not by a whole bunch, that makes me wonder why I would ever reverse with neo/glyco again.

I imagine in 20 yrs we'll tell med students about using the neo/glyco combo and they'll look at us like we're crazy.

 

[Aether2000]

As of September 2018, our hospital cost for a 200mg vial of sugammadex is $103. For 5mg neostigmine plus glycopyrrolate 0.8mg it is $32. Our pharmacy has removed sugammadex from the Pyxis in each OR and relegated it to the central core Pyxis.

 

[deleted162650]

Because reversal is fast and complete and reliable with sugammadex, I’ve been experimenting with extubation first followed by reversal with sugammadex.

I think it’s a reasonable approach . . . Until you need to start chest compressions.

 

[nimbus]

Do you mind sharing your thought process on this?

No tube—->no bucking

 

[nimbus]

I think it’s a reasonable approach . . . Until you need to start chest compressions.

True. It would be nice to have the tube still in if they arrest.

 

[Psai]

True. It would be nice to have the tube still in if they arrest.

Maybe the response to the tube caused the arrest in the first place? I agree with you, I thought about it as well but I'd rather have the tube in for many of the reasons that the tube was placed in the first place.

 

[Twiggidy]

Are these cases short? Excuse my ignorance because my average case is 3hr or longer so I still use Neo/Glyco and almost never redose relaxant unless the surgeon complains and even then I only give a little.

 

[fakin' the funk]

Because reversal is fast and complete and reliable with sugammadex, I’ve been experimenting with extubation first followed by reversal with sugammadex.

I've been wanting to do this. Haven't really had a case where I felt I needed to though.

After all, we put the damn tube IN with the patient don't relaxed, don't we?

 

[fakin' the funk]

Are these cases short? Excuse my ignorance because my average case is 3hr or longer so I still use Neo/Glyco and almost never redose relaxant unless the surgeon complains and even then I only give a little.

You probably practice this way at least in part because of the nontrivial risk of residual NMB with neo+glyco reversal, especially with multiple redoses and deep blockade. So did I, until I got sugammadex. It also means that you are probably using more opioids or propofol or volatile or a different ventilation strategy to keep pt from making respiratory efforts (vs if you used more NDNMB).

Sugammadex has majorly changed my practice. It's awesome.

 

[fakin' the funk]

What are people's practice with respect to timing of standard end-of-case, 2mg/kg sugammadex with >2 ToF twitches administration, on the spectrum from "instant fascia is closed" to "patient is awake and following commands one second before the tube comes out"?

I give it when it would be totally ok from a surgical standpoint for the patient to "express themselves" with their hands

 

[fakin' the funk]

Shop in our area had a similar episode that resulted in intraoperative death, youngish, healthy-ish dude.

I bet there's more to this story.

 

[pgg]

I wonder how many of these bradycardia and asystole events attributed to sugammadex are really vagal responses to coughing and bucking, that suddenly become possible when a patient is abruptly reversed.

I watched a puking OB patient cough and retch and valsalva herself from the 130s to the 50s a couple days ago. Bucking can cause profound vagal responses. As fast as sugammadex works, more and more people are reversing patients further along in the emergence process.

 

[deleted9493]

I wonder how many of these bradycardia and asystole events attributed to sugammadex are really vagal responses to coughing and bucking, that suddenly become possible when a patient is abruptly reversed.

I watched a puking OB patient cough and retch and valsalva herself from the 130s to the 50s a couple days ago. Bucking can cause profound vagal responses. As fast as sugammadex works, more and more people are reversing patients further along in the emergence process.

The bradycardia that I have seen with giving sugammadex to infants/neonates has not been temporally related to coughing/bucking, whatsoever.

 

[Psai]

The bradycardia that I have seen with giving sugammadex to infants/neonates has not been temporally related to coughing/bucking, whatsoever.

Why are your infants and neonates getting suggamadex

 

[Arch Guillotti]

Why are your infants and neonates getting suggamadex

Why not?

 

[deleted9493]

Why are your infants and neonates getting suggamadex

For the same reasons that any other patient gets sugammadex. It is very marginally more expensive at our institution and has had a noticeable impact on the number of NICU patients that I extubate on the table.

 

[epidural man]

I think Merk is so so dumb.

They must be horrible at math.

If they halfed the cost of the drug - EVERY anesthesiologist in EVERY case would use it.

But instead, they have priced it so people still use (frequently i might add), the far more inferior drug neostigmine.

Since we use qualitative neuromuscular monitoring, I base my dose on what I see. If train of 4 is 90% - I don't reverse.

By the way, did you all do the free CME patient safety credits offered on the ASA website earlier (don't know if it is still there)? It was really good stuff on neuromuscular monitoring. It was basically a commercial for suggamadex, but also had some wonderful info.

 

[deleted59964]

For the same reasons that any other patient gets sugammadex. It is very marginally more expensive at our institution and has had a noticeable impact on the number of NICU patients that I extubate on the table.

Cant say I’ve ever changed my mind about extubating a nicu patient based on residual neuromuscular blockade. Babies chew through muscle relaxant fast, but wake up from volatile and opioids slowly ... can you give us more detail?