Suggamedex in ESRD pts

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Noyac

Noyac

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Do you use it?
What side effects have you seen?
What concerns do you have?
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Haven't used it in ESRD, but I guess primary concern is that you will get some dissociation of the Roc/Sug complex over time since it isn't being cleared, and this may result in re-relaxation.
 
Noyac said:
Do you use it?
What side effects have you seen?
What concerns do you have?
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I use it. N=5
I have not seen side effects.
Remember that sugammadex is recommended to be dosed by ACTUAL body weight, but the intravascular volume is way less than that calculated by actual body weight. So we are using doses that have HUGE margins for error.

I have no concerns as the doses of sugammadex we give are so much above the required dose to actually reverse the blockade that even if the elimination of the NMB are slowed down by 50% (only 20-30% in ESRD for ROC and VEC), the liver picks up the rest of the slack.


SaltyDog said:
Haven't used it in ESRD, but I guess primary concern is that you will get some dissociation of the Roc/Sug complex over time since it isn't being cleared, and this may result in re-relaxation.
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This is the theoretical risk. However, but as long as the rate of dissociation is not more than the amount that the liver can breakdown, there shouldn't be any clinically significant re-blockade.

Also, if you give sugammadex, the molecule chelates the NMB but it remains in your system for like 6-9 hours anyways. So the theoretical risk is only slightly increased compared to pts without ESRD.

Now, would I use it in ESLD? I think the answer is also yes, but i have not used it IRL.
 
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The studies that showed the risk of re-curarization to be low were in dogs where they ligated the dogs renal arteries and showed no reparalysis at 48 hours after RSI level doses of Roc and Sugammadex. Essentially there was zero renal clearance during that time. The affinity is simply too high.

Also fun fact: cyclodextrand is super cheap to manufacture (years ago I bought it in 100 gram bottles for bench research--never used all of it), and is the active ingredient in febreeze--which is why febreeze knocks out any bad essential odor.
 
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We used it several times in residency without issues on patients receiving regular HD. I remember doing a brief literature review on it and finding no acute issues in humans with ESRD.

An issue to consider is that since the complex/Sugammadex is primarily cleared renally, you might not be able to re-paralyze with a steroidal neruomuscular blocker (roc/vec) so plan accordingly with a non-steroidal compound (these days, atracurium or cisatracurium).
 
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Most inpatients get dialysis on the day of surgery or post op day 1. Don't know about outpt.
 
AdmiralChz said:
We used it several times in residency without issues on patients receiving regular HD. I remember doing a brief literature review on it and finding no acute issues in humans with ESRD.

An issue to consider is that since the complex/Sugammadex is primarily cleared renally, you might not be able to re-paralyze with a steroidal neruomuscular blocker (roc/vec) so plan accordingly with a non-steroidal compound (these days, atracurium or cisatracurium).
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+1
had to reparalyze with cisatracurium after reversal for some back case.

Also where u getting the atracurium these days?
 
it works fine - haven’t seen any problems.

having said that, so does atracurium... and so does neostigmine/glyco
 
JobsFan said:
huh? is that a thing
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Our pharmacy committee is blaming a case of post-op bradycardia on a dose of Suggs in an ESRD that my partner gave. There were no adverse consequences but these people don’t understand reason always.

For the record, I still use Neo/glyco for reversal. I am not very smooth with sugg yet.
 
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I use sugg regularly. Have seen a few bradycardias but the heart rate usually normalizes once I am ready to pull the tube. I have seen far less emergence delirium. Even though glyco/neo are quarternary its my belief some crosses the bbb and cause ED.
 
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Suggamadex is a drug looking for a problem (great for rapid sequence where you can't give sux or when working with residents or crnas who have no idea how to dose Roc). Otherwise, what's the point? Too bad Neo price increase just happened to coincide with the emergence of Suggamadex. What a coincidence!!!
 
facted said:
Otherwise, what's the point?
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Well, it promotes ideal surgical conditions for fast cases like 15-20 minute lap chole's and appys- in other words you can give 50 mg of Roc and reverse it quickly and reliably. I used to use 25-30 mg of Roc for these cases, but also had to concurrently deepen my anesthestic = higher s/e.
It's biggest draw for me is that it IS better than glyco/neo. Amazingly fast and reliable return of neuromuscular function particulary in those patients that are succeptible to minute residual NM blockade (OB patients, COPD'ers, Obese, pneumonectomies, neuromuscular diseases, etc).
It is definately easier to use without question... and surgeons like it because you can keep patients on the vent (avoiding abdominal breathing) up until the surgeon removes himself from the table. Suggamadex's ability to work at lightning speeds still astonishes me.
It's the best thing that has hit anesthesia practices since propofol. I haven't used glyco/neo for almost a year now.
The ASA always has "free" CME on residual neuromuscular blockade for a reason. It is (or was) a common problem.
 
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sevoflurane said:
Well, it promotes ideal surgical conditions for fast cases like 15-20 minute lap chole's and appys- in other words you can give 50 mg of Roc and reverse it quickly and reliably. I used to use 25-30 mg of Roc for these cases, but also had to concurrently deepen my anesthestic = higher s/e.
It's biggest draw for me is that it IS better than glyco/neo. Amazingly fast and reliable return of neuromuscular function particulary in those patients that are succeptible to minute residual NM blockade (OB patients, COPD'ers, Obese, pneumonectomies, neuromuscular diseases, etc).
It is definately easier to use without question... and surgeons like it because you can keep patients on the vent (avoiding abdominal breathing) up until the surgeon removes himself from the table. Suggamadex's ability to work at lightning speeds still astonishes me.
It's the best thing that has hit anesthesia practices since propofol. I haven't used glyco/neo for almost a year now.
The ASA always has "free" CME on residual neuromuscular blockade for a reason. It is (or was) a common problem.
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There are definitely cases where it's useful. But even for that 20 minute lap chole...30 of Roc and pretty much every patient I've taken care of is reversible (obviously not the mysthenia pts, etc...)
Neo/glyco when fascia is closed it's still a few more minutes until the ports are sutured and you're fine.

There are also issues with Suggamadex, though minor. A) Females on birth control have to use a second method and B) bring backs necessitate cisatracirum. Neither is the end of the world, but can be annoying, especially part A.

Given the similar cost as Neo now, though, it's a better drug for the same price. But if Neo was much cheaper, I would personally give Suggamadex maybe once a year.
 
facted said:
Suggamadex is a drug looking for a problem (great for rapid sequence where you can't give sux or when working with residents or crnas who have no idea how to dose Roc). Otherwise, what's the point? Too bad Neo price increase just happened to coincide with the emergence of Suggamadex. What a coincidence!!!
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Heh

Neostigmine is a dirty drug.

Why wouldn’t you want to use sugammadex ... a NMB reversing drug that’s specific for the the task at hand, works regardless of how dense that block is, works fast ... over a drug that carries a list of muscarinic side effects, won’t work at all if the block is too dense, needs to be given with another drug to offset its side effects (which has side effects of its own)?

Neostigmine is an organophosphate chemical warfare agent. The only reasons to use it these days are if cost/availability of sugammadex are an issue, or if you need to reverse benzylisoquinolines.
 
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facted said:
There are definitely cases where it's useful. But even for that 20 minute lap chole...30 of Roc and pretty much every patient I've taken care of is reversible (obviously not the mysthenia pts, etc...)
Neo/glyco when fascia is closed it's still a few more minutes until the ports are sutured and you're fine.

There are also issues with Suggamadex, though minor. A) Females on birth control have to use a second method and B) bring backs necessitate cisatracirum. Neither is the end of the world, but can be annoying, especially part A.

Given the similar cost as Neo now, though, it's a better drug for the same price. But if Neo was much cheaper, I would personally give Suggamadex maybe once a year.
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Yeah... as it stands now, cost is not an issue and since it's not, then it's the Sugga every single time.
How much Glyco/Neo would you give to reverse 30 mg of roc in a 100 kilo patient after a 20 minute case?
 
sevoflurane said:
Yeah... as it stands now, cost is not an issue and since it's not, then it's the Sugga every single time.
How much Glyco/Neo would you give to reverse 30 mg of roc in a 100 kilo patient after a 20 minute case?
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Usually I'm back to 4 twitches at this point and give 3mg and 0.4 glyco.
 
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My issue with sugg is that I am not very slick with it. I now give a little more prop and fentanyl when I give the sugg in an attempt to not have the pt come off the table 10sec after I give sugg.

So what are you guys/gals doing to achieve that super slick smooth awake up where they just open their eyes when you say their name instead of that look of fear, like where the F am I, that seems to come with sugg?
 
I used suggamadex for every case for 8 months (got it cheap for a while) ... it’s great, never saw a single Brady, or any other issue. I now use it sporadically... it’s just another tool.

Agree that neo/glycol works fine.

Suggs is nice for short cases, when you occasionally get caught out, or even for critical valvular heart disease where giving glyco can cause tachycardia before the neo kicks in.

You do need to warn women of reproductive age on the ocp though.
 
Noyac said:
My issue with sugg is that I am not very slick with it. I now give a little more prop and fentanyl when I give the sugg in an attempt to not have the pt come off the table 10sec after I give sugg.

So what are you guys/gals doing to achieve that super slick smooth awake up where they just open their eyes when you say their name instead of that look of fear, like where the F am I, that seems to come with sugg?
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2 options:

1) Draw up Sugg in a TB syringe and give 0.1 mL at a time

2) Stop doing roc only anesthetics.
 
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pgg said:
That’s a fair point. Neostigmine never got anyone pregnant.
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Birth rates are declining in many countries, thus it might not be a bad thing.
 
Noyac Sugg the patients when the fascia is closed. Then titrate your gas per surgical closure skill level. Look at respiration titrate narcs.
 
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Arch Guillotti said:
Why so?
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By "dirty" I mean it does a bunch of things you don't want it to, the opposite of "clean" ... all the reasons I listed. Undesired muscarinic effects, which are countered, to a degree, by another drug which has side effects of its own.

I'm not saying neostigmine is unsafe. It works (except when it doesn't / 0 twitches).

I'm saying neostigmine is a kludgy, baggage-ridden, roundabout way of reversing NMBs and the only reason we've done it that way is because we didn't have another, better option. Now we do.
 
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pgg said:
By "dirty" I mean it does a bunch of things you don't want it to, the opposite of "clean" ... all the reasons I listed. Undesired muscarinic effects, which are countered, to a degree, by another drug which has side effects of its own.

I'm not saying neostigmine is unsafe. It works (except when it doesn't / 0 twitches).

I'm saying neostigmine is a kludgy, baggage-ridden, roundabout way of reversing NMBs and the only reason we've done it that way is because we didn't have another, better option. Now we do.
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I never really thought of it as being a dirty drug though.
 
Sarin and VX do the same thing neostigmine does.

Pretty dirty IMO.

Suggamadex is phenomenal stuff.

That said, I'm standing by for the "Did you get pregnant because your anesthesiologist gave you Bridion? Call 1-800-BAD-DRUG and sue the bastards!" commercials.

Because I guarantee you they're coming.
 
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Hawaiian Bruin said:
Sarin and VX do the same thing neostigmine does.

Pretty dirty IMO.

Suggamadex is phenomenal stuff.

That said, I'm standing by for the "Did you get pregnant because your anesthesiologist gave you Bridion? Call 1-800-BAD-DRUG and sue the bastards!" commercials.

Because I guarantee you they're coming.
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They are now
 
SaltyDog said:
Do code browns count?
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Haha Salty... touché my friend.

He does have a point. A little Neostigmine does have the ability to make things quite messy for the general surgeon that is maturing the ostomy site when said surgeon has been acting out that day. Silent revenge...

I do miss that aspect, so facted does have a point.
 
Sugg is used widely enough that shouldn't all our consents just say use backup method for 7 days post surgery? Modify your canned consents
Noyac said:
So how is that different from neo/glyco?
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I dont have to deal with a heterotrophic drug that causes multiple issues in the post op phase. Also I am confident the dosing of neo/glyco therapeutic window is very narrow too much residual paralysis too little residual paralysis but different mechanisms. Sugg window is very wide.
 
narcusprince said:
Sugg is used widely enough that shouldn't all our consents just say use backup method for 7 days post surgery? Modify your canned consents

I dont have to deal with a heterotrophic drug that causes multiple issues in the post op phase. Also I am confident the dosing of neo/glyco therapeutic window is very narrow too much residual paralysis too little residual paralysis but different mechanisms. Sugg window is very wide.
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It's not about what your consent says, it's about what inconvenience you put the patient through. Not to mention the theoretical risk of a lawsuit over an unwanted pregnancy when you administered suggamadex...

I totally disagree about the therepeutic window of neo/glyco. When dosed appropriately, I haven't seen any issues. Is suggamadex a "cleaner" drug? Absolutely. But clinically, I think the CLINICAL difference between the two is very small.

If the cost differential remains small, give it all you want in male patients and be careful in females of child bearing age. But if you get Neo for cheap, then I absolutely don't understand the instinctive rush to use it. One too many suggamadex dinners.
 
For me right now the cost difference between neo/glyco and sugga is like $5. They're both very expensive.

I think the Bloxiverz guys screwed up in their attempts to be greedy. A price point $10-15 less would change the calculus back in its favor.

But that's the free market at work.
 
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facted said:
nd the last time you had a clinic issue because of this was...?
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So after some thinking, I think I do have a recent case where Neo/Glyco caused some problems. It was actually the case I discussed in the complete heart block thread. A lil' ol' lady for a chest case that went into complete heart block on me in PACU. She had some conduction problem on pre-op EKG, but for the life of me I can't remember exactly how it was read. I was not your garden variety BBB though. Something nodal I think. Anyways, I think in this case the neostigmine caused her to Brady which was not counteracted by the glyco since the ventricle won't respond to anticholinergics and the atrial signals weren't making through. Maybe I'm reaching, but that's all I could think at the time. The timing was right. If I was doing her case again, I would reverse her with Sugga.

Disclaimer: I still use Neo/Glyco >90% of the time even though Sugga is in the cart. I just feel dirty using Sugga - it's toooo easy. **** is downright magical.
 
I personally don’t even think the fact that neostigmine is literally a poison and has multiple side effects when used appropriately is the worst part. Now, I’ll give all you guys that do hands on cases a pass here, but in care model practices, or with trainees I think neostigmine overdose is by far the biggest deal. I can’t tell you how often I ask “what was given for reversal” when evaluating for extubation and the resident or crna defensively answers with “full dose or full reversal with neo!”. They answer as if the question implies I don’t believe the Pt looks strong and thus must be implying they under-reversed.

But I think giving “5 and 5” (5mg neo and 1mg glyco) to people is crazy, I’m sure it actually leads to postop weakness and atelectasis etc but a lot of people do that incorrectly believing more is better when reversing NMB. In that regard alone I think Sugammadex is the answer if Roc was used and cost is even close to the same.
 
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IME neostigmine is clearly clinically inferior. I’ve seen MANY cases of inadequate reversal with neostigmine over my career. I’ve NEVER seen that with Sugammadex. Makes no sense to keep using neostigmine.
 
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SaltyDog said:
Disclaimer: I still use Neo/Glyco >90% of the time even though Sugga is in the cart. I just feel dirty using Sugga - it's toooo easy. **** is downright magical.
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Easy and magical=good. Why make things hard for yourself?
 
facted said:
It's not about what your consent says, it's about what inconvenience you put the patient through. Not to mention the theoretical risk of a lawsuit over an unwanted pregnancy when you administered suggamadex...

I totally disagree about the therepeutic window of neo/glyco. When dosed appropriately, I haven't seen any issues. Is suggamadex a "cleaner" drug? Absolutely. But clinically, I think the CLINICAL difference between the two is very small.

If the cost differential remains small, give it all you want in male patients and be careful in females of child bearing age. But if you get Neo for cheap, then I absolutely don't understand the instinctive rush to use it. One too many suggamadex dinners.
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I have to disagree about the clinical difference. My place is doing some studies about the difference in times of reversal. And it isn’t even close. Granted, we are using accelerometer and not pulling tubes until the the TOF ratio is >0.9, but the time to get there between the two is greater than double digits in minutes. And remind me, how much does a minute of OR time cost again?
 
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