The End of Sux?

[EM Guy]

---

Members don't see this ad.

What do you guys think about this? It's being touted as a reversal agent for Roc currently undergoing FDA investigation.

http://www.rocuroniumuk.com/view.aspx?id=81

Is this legit? If so, with the ability to reversibly perform RSI without all the nasty side-effects of sux, will this be the death of sux in the clinical arena?

Or, is this a moot point? Please forgive me if I'm wrong, but my understanding is that high-dose vec can be used for rsi with very good intubating conditions. Further, that a single dose of vec at 0.1 -0.15mg/kg can be reversed (neostigmine/glycopyrrolate, etc) WITHOUT the use of a twitch monitor. Could you theoretically use this combination in a failed RSI situation where you may want to take away the paralytic?

Thanks in advance

 

[EM Guy]

Sorry, just noticed the previous thread addressing the same reversal agent. Still interested in if you think that a blind reversal of carefully dosed vec is safe, and if you think that sux will disappear if this new med is approved.

 

[rn29306]

..

 

[rn29306]

Please forgive me if I'm wrong, but my understanding is that high-dose vec can be used for rsi with very good intubating conditions. Further, that a single dose of vec at 0.1 -0.15mg/kg can be reversed (neostigmine/glycopyrrolate, etc) WITHOUT the use of a twitch monitor. Could you theoretically use this combination in a failed RSI situation where you may want to take away the paralytic?

What dosage constitutes high-dose vec? We will use low-dose vec (0.07 mg/kg) for cases around 30 minutes, but I have never heard of high-dose vec.

If you attempted to reverse (at my facility) vec at the dosages you listed after a failed RSI you would get the beat down of a lifetime. A twitch monitor will be useless in this situation anyway - there won't be a twitch for some time.

 

[Skrubz]

i've been taught that "high-dose" vec can indeed be used for a more rapid onset (though it still lags behind RSI-dose roc) and that approximate times are:
sux: 45-60 sec
RSI-dose roc (1.2 mg/kg): 60-90 sec
high-dose vec: ~90 sec

Pubmed abstract: Onset and duration of neuromuscular blockade following high-dose vecuronium administration.

however, if you try to reverse any kind of nondepolarizing muscle blocker before you have twitches back (even if it's a single post-tetanic twitch) or any sign of neuromuscular function (like overbreathing the vent), all you'll do is prolong the blockade and shoot yourself in the foot. you don't necessarily *need* to check twitches before reversing... on my peds cases i've rarely been checking twitches, mainly because the surgeons like to drag the kids to the end of the bed and i can't get to either the hand or the head, so i just get them to start overbreathing the vent and then reverse them. but if you reverse without any sign/verification of neuromuscular activity, you're taking a risk, even if it's been long enough that it should've worn off.

that's a problem with doing RSI with nondepolarizers - if you can't intubate and can't ventilate either, you're screwed because you can't reverse after giving that ginormous dose - and why this new reversal agent could be so revolutionary.

however, sux probably won't completely disappear... i've been taught that muscle blockers (particularly nondepolarizers) are actually one of the most allergenic drugs that we give in the OR (though i've yet to see someone who's allergic to roc or vec). and the new reversal agent certainly won't be cheap, so it could go the way of halothane - not used routinely in the US but still used outside. though i do wonder if pedi anesthesia will change from having a syringe of sux as an emergency drug for laryngospasm to having a stick of roc...

 

[Idiopathic]

90 seconds for onset, has always seemed like an eternity when you are dong an RSI on the floor at 2AM. Never seen it used (at three institutions) for RSI in the OR.

 

[stephend7799]

Nothing Will Replace Succ

Never

Thats Why Its Been Around For 50 Years And I Still Draw It Up On Every Single Case I Do.. Period.

 

[jetproppilot]

Nothing Will Replace Succ

Never

Thats Why Its Been Around For 50 Years And I Still Draw It Up On Every Single Case I Do.. Period.

I almost totally agree with you.

I use sux frequently. It speeds everything up. I'm not bagging for a cuppla minutes.

Roll in, pt on table, fentanyl 100 ug, rocuronium 5 mg.

Monitors on.

Cycle the BP cuff while you position the circuit into the Xmas tree (i.e. circuit holder) so the mask sits on the pt's face. Or have the circulator hold the mask on the pt's face.

Grab the IV, push the propofol......

Then say over and over, like Rain Man,

"HOW YA DOIN?"

"fine"

"HOW YA DOIN?"

"ffffffffffffiiiiiiiiiiiiiiiiiiiiiiiiiiiinnnnnnnnnnnnnnnnnnnnnnnnnnnnnneeeeeeeeeeeeeeeeeee"...

time to push the sux.

no need to ventilate.

Then, if you're bored, squeeze the bag for 30 seconds.

If you're putting to sleep an ASA 1 who's been preoxygenated, recall the purpose of preoxygenation (displacement of nitrogen from FRC), then recall the rate of oxygen consumption in a healthy adult (meaning you are buying yourself ALOTTA time before desaturation), then realize, after adequate oxygenation on a patient with healthy lungs, you could probably preoxygenate, give propofol/sux, leave the room, walk to the OR mens room, take a whiz, walk back to the OR, reenter the room, and dude's SaO2 would still be above 90.

Sorry about the tangent.

I like sux too.

They tried with rapacuronium. Its not around anymore.

Sux still is,

 

[IceDoc]

What do you guys think about this? It's being touted as a reversal agent for Roc currently undergoing FDA investigation.

http://www.rocuroniumuk.com/view.aspx?id=81

Is this legit? If so, with the ability to reversibly perform RSI without all the nasty side-effects of sux, will this be the death of sux in the clinical arena?

Or, is this a moot point? Please forgive me if I'm wrong, but my understanding is that high-dose vec can be used for rsi with very good intubating conditions. Further, that a single dose of vec at 0.1 -0.15mg/kg can be reversed (neostigmine/glycopyrrolate, etc) WITHOUT the use of a twitch monitor. Could you theoretically use this combination in a failed RSI situation where you may want to take away the paralytic?

Thanks in advance

Most of the high dose vec for RSI was picked up in the ER literature. At least around here, it's fallen by the wayside because the incidence of failure to ventilate/intubate was too high. Think about it, 30mg of Vec for a 70kg person....be waiting for hours for it to wear off.

 

[adleyinga]

Most of the high dose vec for RSI was picked up in the ER literature. At least around here, it's fallen by the wayside because the incidence of failure to ventilate/intubate was too high. Think about it, 30mg of Vec for a 70kg person....be waiting for hours for it to wear off.

Nothing will replace sux- agreed, but having the new reversal agent will make those RSI cases where sux is contraindicated "alittle" less scary

Unless of course my hospital refuses to buy it because too expensive.

Be aware the new stuff does not wrok as well on vec.

.2 mg of vec works well for RSi but can't reverse rapidly

 

[EM Guy]

Thanks for the insights.

We use vec not infrequently in the ED for routine intubations (e.g. not RSI). Usually get a nice view after 60 seconds. Only had to pull the blade out and wait a bit longer for better relaxation a handful of times. Generally makes for a smooth intubation.

As an aside, we use roc for all RSI in kids with unknown PMH. Are there any data suggesting/showing that sux delivers significantly better intubating conditions that sux? Seems that with all the sinister side effects of sux, that roc makes sense for RSI in kids. Beyond the obvious of course, that the half-life of roc is so long and makes can't ventilate/can't intubate that much more dire.