sux-induced myalgia

[dfk]

i'm not trying to sound like a cowboy or anything,
but i'm just wondering if anyone has had experience
(or guts) pretreating induction of sux with calcium gluconate.
i have read somewhere that doing this will decrease
the release of potassium and help decrease degree of sux-induced myalgia...

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[LongSnow]

Never given calcium for that reason - nor have I ever heard of it reducing myalgias. Have heard of and tried defasciculating doses and Iv lidocaine - both with questionable efficacy.

However, I do think that for routine run-of-the-mill surgeries that require intubation, patient post-op will sometimes complain more about the myalgias than any thing else if sux is used!

I rarely will use sux, and when I do, will usually give a pre-fasciculating rocuronium (10-20mg) dose. Can intubate most people atraumatically with larger doses of propofol (3mg/kg) and a little narcotic, and some sevo masking once asleep. Those fasciculations have always given me the heebie geebies!

 

[coprolalia]

Avoid succinylcholine whenever possible, especially in young, healthy patients. The post-op myalgia is excrutiating. I know this firsthand. Feels like you have been flattened by a steamroller. Literally every muscle in my body ached for two days. It felt like I'd just played a Division I collegiate football game without wearing any pads. Why that ***hole used sux on me I'll never know. I wasn't being a jack*** or anything like that before I had my surgery. Ironically (or not), the best anesthetic I've had (five total) was administered by a nurse anesthetist. All my surgeries/anesthetics were well before I went to medical school. I didn't know jack back then about anesthesia. Now that I do and realized what happened to me, I'd be more likely to push a massive NMB dose in a young healthy patient in order to get to intubating conditions quicker (if I don't think the airway is going to be an issue) rather than use sux. When we finally get sugammadex, you'll be hard-pressed to justify using sux anymore.

-copro

 

[dfk]

sugammadex will be the bomb.
i don't believe nothing can truly "replace" sux though
(30-60 seconds intubating conditions),
even though roc has "near" sux
qualities at 1.2mg/kg (near 60 seconds).
supposedly phase 2 'gantacurium' will have
intubating conditions of 60 seconds.

 

[coprolalia]

sugammadex will be the bomb.
i don't believe nothing can truly "replace" sux though
(30-60 seconds intubating conditions),
even though roc has "near" sux
qualities at 1.2mg/kg (near 60 seconds).
supposedly phase 2 'gantacurium' will have
intubating conditions of 60 seconds.

The more NMB you push, the faster you'll "get there" for intubation. This is true for all NMB's. The only downside I can see with pushing an escalated dose of Roc is that you may subsequently have an allergic reaction to contend with.

-copro

 

[Planktonmd]

The more NMB you push, the faster you'll "get there" for intubation. This is true for all NMB's. The only downside I can see with pushing an escalated dose of Roc is that you may subsequently have an allergic reaction to contend with.

-copro

With "Allergic reactions" I assume you mean IGE mediated immediate reactions?
These reactions can be triggered by any dose.
If you mean Anaphylatctiod type histamine release then yes, dose matters.

 

[coprolalia]

If you mean Anaphylatctiod type histamine release then yes, dose matters.

Correct. Anaphylactoid reaction. Anaphylactic reactions (Type III) to roc are not as common, and require previous "sensitizing" dose of the NMB.

Thanks, Dr. Pedant.

-copro

 

[dfk]

i agree that larger doses = faster onset
don't forget that these larger doses
also = longer duration (sometimes roughly 2-3xs the regular duration).
sometimes, this could last longer than surgery.
but with sugammadex, who cares? (save for the histaminergic/anaphylactoid rxns)

 

[deleted9493]

Correct. Anaphylactoid reaction. Anaphylactic reactions (Type III) to roc are not as common, and require previous "sensitizing" dose of the NMB.

Thanks, Dr. Pedant.

-copro

Type III, hmmm?

 

[amyl]

not to be an immuno-nazi or anything but anaphylaxis/immediate hypersensitivity/IgE is type I. Type III is immune complex mediated. (II -- cytolytic antibody mediated, IV cell mediated/delayed hypersensitivity.)

 

[Planktonmd]

not to be an immuno-nazi or anything but anaphylaxis/immediate hypersensitivity/IgE is type I. Type III is immune complex mediated. (II -- cytolytic antibody mediated, IV cell mediated/delayed hypersensitivity.)

Correct

 

[coprolalia]

Jeezus, more pedantics! Okay, Type I. I get it. Christ. Sorry, I'm human.

not to be an immuno-nazi or anything but anaphylaxis/immediate hypersensitivity/IgE is type I. Type III is immune complex mediated. (II -- cytolytic antibody mediated, IV cell mediated/delayed hypersensitivity.)

Furthermore, have you ever seen this reacton, namely a full-blown "anaphylactic shock" reaction to rocuronium? I have. The interesting part is it occurred 20 minutes after the roc was given. I'm not really sure how you explain that with the classic IgE-mediated Type I type reaction, which is explosive and happens in the space of about one circulation time around the body. Either way, "classic theory" doesn't really adequately explain this observation. The patient had the roc, became fully relaxed, and then had the reaction. Figure that one out.

-copro

 

[DreamMachine]

.

 

[Planktonmd]

Jeezus, more pedantics! Okay, Type I. I get it. Christ. Sorry, I'm human.



Furthermore, have you ever seen this reacton, namely a full-blown "anaphylactic shock" reaction to rocuronium? I have. The interesting part is it occurred 20 minutes after the roc was given. I'm not really sure how you explain that with the classic IgE-mediated Type I type reaction, which is explosive and happens in the space of about one circulation time around the body. Either way, "classic theory" doesn't really adequately explain this observation. The patient had the roc, became fully relaxed, and then had the reaction. Figure that one out.

-copro

This is exactly what an anaphylactoid reaction is: Looks like anaphylaxis but there is no Antigen-Antibody interaction and there is no IGE involved.
It's not a "allergic reaction" as you keep saying, and certainly not a type 1 reaction.
It's similar to what you see with Dextran and many other drugs, maybe direct effect on the mast cells.

 

[coprolalia]

This is exactly what an anaphylactoid reaction is: Looks like anaphylaxis but there is no Antigen-Antibody interaction and there is no IGE involved.
It's not a "allergic reaction" as you keep saying, and certainly not a type 1 reaction.
It's similar to what you see with Dextran and many other drugs, maybe direct effect on the mast cells.

Well, if you're talking about Dextran, you're probably talking about a Type III hypersensitivity reaction. Keep it straight.

And I understand the distinction, Plank. Most people call the anaphylactoid reaction anaphlyactic. Even the Allergist we consulted did, because the tryptase level was up. The point is, tryptase can be up in an anaphylactoid reaction as well.

They guy had had rocuronium about 3 years prior. He also had positive subsequent intradermal testing.

You tell me: Type I, or anaphylactoid based on that info?

-copro

 

[coprolalia]

How did you know it was the roc?

See above. Patient had subsequent allergy testing.

-copro

 

[Planktonmd]

Well, if you're talking about Dextran, you're probably talking about a Type III hypersensitivity reaction. Keep it straight.

And I understand the distinction, Plank. Most people call the anaphylactoid reaction anaphlyactic. Even the Allergist we consulted did, because the tryptase level was up. The point is, tryptase can be up in an anaphylactoid reaction as well.

They guy had had rocuronium about 3 years prior. He also had positive subsequent intradermal testing.

You tell me: Type I, or anaphylactoid based on that info?

-copro

Sure, I can tell you with certainty that if the reaction was not immediate after IV administration of a drug then it is not type 1.
The reason I mentioned Dextran is because it's an example of an anphylactoid reaction regardless of the mechanism, and you are partially right, a type 3 IgG mediated reaction is one of the suggested explanations for it although other explanations exist as well.
By the way, when you say "allergy" it's generally understood that you are talking about an IGE mediated event not any other Immune reaction.

 

[jwk]

I rarely will use sux, and when I do, will usually give a pre-fasciculating rocuronium (10-20mg) dose.

That's a boatload of roc for a defasciculating dose. I generally use 5mg and WAIT a couple of minutes, just like when we used to use DTC. If you're not going to wait and give it a chance to do it's thing, or if you're giving them a half-loading dose anyway (which you are), you might as well not use sux at all.

Sux still has a place IMHO. Lots of folks don't use it or are just downright scared to use it. Like everything we use, there's a time and place.

 

[jetproppilot]

That's a boatload of roc for a defasciculating dose. I generally use 5mg and WAIT a couple of minutes, just like when we used to use DTC. If you're not going to wait and give it a chance to do it's thing, or if you're giving them a half-loading dose anyway (which you are), you might as well not use sux at all.

Sux still has a place IMHO. Lots of folks don't use it or are just downright scared to use it. Like everything we use, there's a time and place.

DTC was the bomb!

Give 1 mL (was that 3mg?)....nobody ever got weak....worked excellent.

Roc is a mixed bag for defasic.....5 mg is hard to time....dont wait long enough and it doesnt work.....wait too long and an unacceptable % will feel some sort of uncomfortableness....

I like giving 10mg roc followed immediately by the propofol....seems to work the best IMHO if you wait 60 sec, and this eliminates the potential for that scary weak feeling which I really hate to see. Guess its one of my pet peeves.

I still like sux for the cases that require a tube but are short...very easy to have a weak pt at the end of these cases if using roc as your nmb even if you underdose the roc on induction.

Like I said, DTC was DA BOMB. Ashame its not available anymore.

 

[jwk]

DTC was the bomb!

Give 1 mL (was that 3mg?)....nobody ever got weak....worked excellent.

Like I said, DTC was DA BOMB. Ashame its not available anymore.

Yep - DTC 3mg was 1cc - some places even had pre-filled syringes from the manufacturer.

And all you weanies out there worrying about a little histamine release from some roc - try doing a whole case with DTC - 30mg or so - I'll show you some friggin histamine release!

 

[jetproppilot]

Yep - DTC 3mg was 1cc - some places even had pre-filled syringes from the manufacturer.

And all you weanies out there worrying about a little histamine release from some roc - try doing a whole case with DTC - 30mg or so - I'll show you some friggin histamine release!

When I was a resident, JWK, just for fun, for some big back cases I used morphine and DTC in a nitrous narcotic technique....would intubate on DTC (forgot the dose...... .5mg/kg maybe?) morphine 1mg/kg up front....a little background iso and midaz 2mg/hr for amnesia....

exploited the hypotension from the histamine from the DTC and morphine..

worked like a charm!

thats some cool old-school controlled hypotension, huh?

 

[coprolalia]

... in a nitrous narcotic technique....

That's called the Liverpool technique, and it had a very high incidence of awareness under anesthesia.

-copro

 

[jwk]

When I was a resident, JWK, just for fun, for some big back cases I used morphine and DTC in a nitrous narcotic technique....would intubate on DTC (forgot the dose...... .5mg/kg maybe?) morphine 1mg/kg up front....a little background iso and midaz 2mg/hr for amnesia....

exploited the hypotension from the histamine from the DTC and morphine..

worked like a charm!

thats some cool old-school controlled hypotension, huh?

Sounds about right on the dose - I remember giving in the neighborhood of 30mg or so.

Controlled hypotension via deliberate and semi-controlled histamine release - ya gotta love it!