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Post by katevaughn on Jul 31, 2018 13:31:58 GMT -5
This month’s journal club is presented by Ben Waldbaum. He chose an excellent article that takes a look into muscle relaxant induced anaphylaxis. Always a topic to review and further study to increase the safety of our practice! Given the recent discussion regarding anaphylaxis and relation to muscle relaxants, Ben thought the attached article would be timely. Also, he heard some suggest that sugammadex can be used to reverse rocuronium induced anaphylaxis. The current literature does not support this and shows that it does not affect outcome.
Here is a link to the article. Analphylaxis20to20Neuromuscular20blocking20....pdf (233.2 KB) The questions to encompass within your response: 1.) Frequently when I take over cases, I see that more than a single muscle relaxant was administered, such as both rocuronium and vecuronium. According to this article, the cross reactivity rate of patients with a rocuronium allergy also being allergic to vecuronium is about 40 percent. This means there is a significant chance that one who is NOT allergic to vecuronium may be allergic to rocuronium or vice versa. Knowing this, is it bad practice to administer more than one non-depolarizing muscle relaxant to a single patient, especially since of all the drugs anesthesia providers administer, only antibiotics have a higher incidence of anaphylaxis? Why take a chance and administer muscle relaxant B after a patient already tolerated muscle relaxant A? 2.) Rocuronium had 8 incidents of anaphylaxis per 100,000 exposures with a range of 5.8 to 11. Vecuronium had 2.8 incidents of anaphylaxis per 100,000 exposures with a range of 1.3 to 5.3 with the p-value for the difference between the two at 0.0013. Based on this, the incidence of rocuronium induced anaphylaxis is more common. Discuss reasons why a clinician may still prefer rocuronium. Is the incidence still low enough that there is no reason to prefer one over the other?
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Post by LarSharVeA Bennett on Aug 1, 2018 11:56:18 GMT -5
I have taken over cases where both rocuronium and vecuronium were used as well. I once asked the provider why. The reason stated was that vecuronium had a longer onset. This provider believed that rocuronium would better facilitate a more rapid intubation in a patient with a difficult airway. Fair enough, but then why not continue with rocuronium boluses intraoperatively? It is understood that succinylcholine would not be the NMB of choice in the patient that is hyperkalemic, even those with fibermyaglia or other chronic pain syndromes because of the discomfort associated with fasiculations (we could explore this more); however, I find that rocuronium is rarely administered in rapid sequence doses. Rather, 50mgs is given more often than not regardless of the patient's weight, so optimal intubation time may be comparable with rocuronium (in the dosages commonly administered) and vecuronium.
Years ago, I read an article about the antitussive pholocodine, that is commonly used abroad. Pholocodine is structurally a quaternary ammonium and has been associated with anaphylaxis associated with the aminosteroidal NMB and sugammadex. I am curious if anaphylactic reactions to the aminosteroidals are more common abroad.
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Post by Kristen Horsman on Aug 6, 2018 8:02:50 GMT -5
1. As I student, I also faced preceptors who would use rocuronium for induction and vecuronium for maintenance paralysis. The preceptors' reasoning was similar to LaSharVea in that they wanted a faster induction, but that vecuronium was more "consistent" and "predictable" meaning that they would know the patient would have a twitch back in x amount of time with vecuronium vs. rocuronium there was more variability in time x with the same doses.
2. Onset
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Post by aileenm4 on Aug 9, 2018 12:58:06 GMT -5
As an FYI: The June newsletter for APSF anesthesia patient safety foundation had an article “ current status of Sugammadex usage and The occurance of Sugammadex -induced anaphylaxis in Japan” The findings stated were that the incidence of Sugammadex anaphylaxis maybe similar to those of Succinylcholine and Rocuronium. Anesthesia providers should observe patients in the operating room for at least 5 minutes for s/s of anaphylaxis (airway edema, bronchospasm) after the administration of Sugammadex. I know that I have been using Sugammadex more often as a reversal agent if I use Rocuronium. I myself do not routinely switch agents for muscle relaxation. We all can take a moment to review the algorithm for treatment of anaphylaxis since it can happen anytime.
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Post by belinda on Aug 16, 2018 16:14:38 GMT -5
This is an interesting article and certainly makes me evaluate my practice as I often do induce with Rocuronium to achieve optimal intubating conditions more rapidly than Vecuronium, then will use Vecuronium for maintenance for it's predictability. The cases where a patient may end up "unreversible" at the end of a case is usually when Rocuronium has been given throughout the case but now that Suggamadex is available probably not so much of a worry except that these same patients may also have the potential for anaphylaxis to it as well.
It might be worth noting that this study admits a small sample size and more importantly taking place in Australia where the community is most likely sensitized by exposure to pholcodine a morphine analogue (as LarSharVea touched upon) which is used frequently as an antitussive there as well as other countries in Europe which increases the risk 300 fold for having anaphylaxis to NMB's by creating anti-suxamethonium antibodies. For this reason it is not used in the US (classified schedule 1) and has been removed for use in other countries so the rates of anaphylaxis can probably not be extrapolated to other countries.
With having a large international population coming for surgery here to our institution it may be worth noting where our patients are coming from and their use of over the counter cough medications when considering our neuromuscular blockade of choice. Our pharmacy does not have a rate of anaphylaxis on record to Rocuronium for the institution.
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khall
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Post by khall on Aug 21, 2018 8:15:10 GMT -5
I personally do not like to switch between NDMR, if I start with Rocuronium I continue with it throughout the case. Despite the increase in anaphylaxis I find myself far more likely to reach for Rocuronium due to its onset. Especially with the availability of Suggamadex, I no longer fear being unable to reverse at the end of the case. After reading this article, it seems slightly reckless to choose Rocuronium simply for a more speedy induction.
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kty67
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Posts: 22
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Post by kty67 on Aug 21, 2018 8:21:42 GMT -5
1. I agree with responses above that anesthesia providers (CRNAs and MDs) use Rocuronium for faster induction and continue the case with Vecuronium because of it's predictability. I was one of those providers since it was frequent preference of my preceptors. But after reading several articles about Rocuronium anaphylaxis rates I use mainly Vecuronium if I can take my time with induction. I try to change my practice to only one paralyzing agent. 2. Onset of Rocuronium is faster.
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Post by jessica switzman on Aug 21, 2018 15:29:14 GMT -5
1. I start with Rocuronium but switch to Vecuronium after 150 mg of Roc or during long cases despite the increase potential for anaphylaxis. I have also started with Vec and switched to roc. Despite this article; I believe there is nothing wrong with it. Roc has a much faster onset but is intermediate acting like vec
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Post by Ben Waldbaum on Aug 22, 2018 12:53:20 GMT -5
1.) I believe best practice would be to limit the number of muscle relaxants used. Whichever is chosen for induction should be stayed with for the duration of the case as long as the patient tolerates that muscle relaxant.
2.) The incidence of anaphylaxis is still low enough that it is reasonable to use either vecuronium or rocuronium. Rocuronium has an advantage of faster onset.
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Post by Soo-Ok Kim on Aug 24, 2018 17:57:41 GMT -5
In general, I minimize the number of medication that I give including muscle relaxant unless it is necessary because I believe every drug has side effects as well as unexpected reaction like allergy. If I need to use muscle relaxant, I prefer vecuronium especially pediatric population for more predictable pharmacokinectics. If I use rocuronium for induction, I keep rocuronium for the case. There was an article (cannot recall what) suggesting that sugammadex can cause neuronal cell apoptosis if there is left over amount in the blood stream. I thought that was interesting to consider since we are now using so much now.
I will still use rocuronium when indicated for RSI since benefit/risk ratio for anaphylaxis with it is smaller than possible complications with airway.
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Post by emedina1 on Aug 26, 2018 15:47:29 GMT -5
I have known that some muscle relaxant will induce some kind of reaction. With this in mind I tend not to mix my drugs this is from the old school thought. In my recent practice, muscle relaxation is not really a priority, however i use roc for the short duration of the surgery. I do redose with thew same drug.
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Post by Moishe Mayer on Aug 27, 2018 23:34:16 GMT -5
1. I think it makes sense to stick to one agent, especially if it has already proven to be safe for a specific patient. Often we are faced with paralytic shortages. For example, during a long case, the pyxis may run out of Rocuronium, and only have Vecuronium left. So if the patient suddenly needs relaxation, the CRNA would have to act swiftly and use what is available.
2. In general, since vecuronium is proven to be a safer drug, we should be using this on all patients to limit their possible allergic reactions to the many different drugs that we use. Of course, Roc has its place. For example, when a quicker onset is needed (RSI 1.2mg/kg). Also, Bridion has slightly better binding to Roc, which can also play a role.
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Post by Jessica Hadley on Aug 29, 2018 13:18:40 GMT -5
1. I typically prefer to use the same NMD throughout a case, however I understand the rational of those who use Rocuronium for induction and the switch to Vecuronium for maintenance. I hadn't thought of avoiding switching due to a concern for anaphylaxis, but it makes sense that any time you administer a new drug you are risking a reaction.
2. I more routinely use Vecuronium because that is what I used most commonly in training and personally have never seen an allergic reaction after Vecuronium administration. I have found that I am using Rocuronium more often since the introduction of Suggamadex for reversal, especially in cases where there is not a need to redose NMD following intubation. This article has reminded me that there is always a risk of reaction and we should have a rational for every drug we give especially when alternatives are available that may carry an overall lower risk.
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Post by Wai-Ling Lo on Aug 29, 2018 16:57:28 GMT -5
1.)
I agree that the best practice should be staying with one type of NDMR and have appropriate clinical indications for our choices (see below). Moreover, it's also crucial to be able to recognize the symptoms of anaphylaxis, treat promptly, perform appropriate lab tests to aid diagnosis (e.g. serum histamine and tryptase), and arrange for post op placement and follow up. (Note: we now have the I-care tab for quick reference of anaphylaxis management). More recent research suggests that sugammadex may attenuate the rocuronium-induced anaphylaxis and dosing should be at 16mg/kg in order for all rocuronium molecules to be encapsulated. However, further studies are needed to valid the hypothesis.
2.)
Rocuronium is preferred than vecuronium because of:
a. faster onset: Rocuronium (89 +/- 33 s) versus vecuronium (144 +/- 39 s)
b. BETTER intubation condition
These advantages are especially vital for patients who are difficult to mask, or have potential difficult airway/aspiration risk from gastric insufflation/vocal cord issues.
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Kristen Praesel Lang
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Post by Kristen Praesel Lang on Aug 29, 2018 20:25:49 GMT -5
1.) I have also taken over cases where more than one muscle relaxant was used. I believe this is oftentimes due to the quicker onset of rocuronium for more favorable intubation conditions and then vecuronium is used for maintenance during the case. In my own practice, I tend to stick with one muscle relaxant for the duration of the case.
2.) The article makes you consider your NMB drug selection for cases. Generally, I tend to use vecuronium for most cases. However, rocuronium is my go to in cases that are expected to be shorter in duration.
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