July FY23

[kristenhorsman]

This month's journal article is presented by Kristen Roman. She chose an article reviewing muscle relaxants and reversals. 

Please use the attachment in the email, because Current Reviews require a membership, and answer the following two questions:


1. What is the induction dose of succinylcholine and rocuronium? Do you/your attending consistently give these doses or do you find patients requiring >100mg succinycholine or >50mg rocuronium are frequently underdosed? 
2. What do you primarily use as your reversal agent(s)? What are the pros/cons you weigh when giving sugammadex vs. neostigmine/glyco? 

[nanci]

1. What is the induction dose of succinylcholine and rocuronium? Do you/your attending consistently give these doses or do you find patients requiring >100mg succinylcholine or >50mg rocuronium are frequently under dosed?
Succinylcholine induction dose is 1-1.5 mg /kg and Rocuronium listed as 0.6-1 mg/kg with RSI dosing of 1-1.2 mg/kg. I find that often times these are the doses given consistently. Of note, when in ECT the dosing of succinylcholine is sometimes titrated down or up from a starting dose of 1-1.5mg/kg depending on patient condition and response for the patients subsequent treatments.

2. What do you primarily use as your reversal agent(s)? What are the pros/cons you weigh when giving sugammadex vs. neostigmine/glyco?
Lately the primary reversal agent has been Sugammadex as it generally gives less respiratory weakness in PACU, has a fast onset, is only the one medication being administered, appears to be available (so far), and does not appear to increase PONV. Cons to Sugammadex would be that it is expensive, only reverses rocuronium and vecuronium, and more allergenic than Neostigmine.

[Dahlia Rouchon]

Thank you for this article and review regarding muscle relaxation, agents and its' reversal options..

1. The induction dose for anectine is 1-1.5mg/kg. For rocuronium it is 0.6-1.2mg/kg.

We (working with different providers) do not consistently give these doses due to: 1. co-morbidities/pmh/clinical presentation of the patient {for anectine} 2. perceived length of surgery {for zemuron} or 3. to decrease potential for myalgias with anectine. If anything, I observe, 100mg is under dosed for the morbidly obese and more frequently we give the 1.5mg/kg for anectine with these patients. What is of more common issue is not waiting the necessary time for the medication to be most effective at the moment of laryngoscopy. I believe we may under dose with 50mg zemuron, in addition to not waiting for appropriate time to DL. I prefer to use 1-1.2mg/kg for zemuron and proceed.

Using a nerve stiumlator or accelerometer is helpful as well as feeling compliance on the bag to know when to begin intubation.

2. I primarily use sugammadex for reversal given it's quick and consistent result for recovery of paralysis. The pros of sugammadex I have seen is better recovery with a deep block. I still wait for a minimum 1 PSTT to 1/4 TOF and give a higher dose of the reversal, then check for tetanus prior to extubation to confirm desired results. I typically use a NIF test to confirm strength if I am concerned about poor recovery of paralysis.

I would use sugammadex if the reversal provided by neostigmine and robinul were not sufficient. The con to sugammadex would be previous allergic reaction with hives, refractory hypotension albeit these episodes have occurred with no previous exposure to sugammadex. I may not use sugammadex for ESRD patients (as recommended by the manufacturer). I keep in mind as well the post-market experience warning for sugammadex from Merck-

Cases of marked bradycardia and bradycardia with cardiac arrest have been observed within minutes after administration of sugammadex. Other cardiac rhythm abnormalities have included atrial fibrillation, atrioventricular block, cardiac/cardiorespiratory arrest, electrocardiographic (ECG) ST segment changes, supraventricular tachycardia/extrasystoles, tachycardia, ventricular fibrillation, and ventricular tachycardia. Anaphylaxis associated with ECG ST segment changes (elevation or depression) consistent with myocardial ischemia or coronary spasm has also been reported.

Prudent preparation to manage these complications are required. In the case of bradycardia if I must use a larger dose of sugammadex, I typical give it in aliquots over 5 minutes.

[kels]

1. What is the induction dose of succinylcholine and rocuronium? Do you/your attending consistently give these doses or do you find patients requiring >100mg succinycholine or >50mg rocuronium are frequently underdosed?
Succinylcholine induction dose is 1-1.5 mg /kg
Rocuronium dose is 0.6-1 mg/kg and RSI dose is 1-1.2 mg/kg
Usually the the amount of muscle relaxant given to my patients matches the recommended dosing


2. What do you primarily use as your reversal agent(s)? What are the pros/cons you weigh when giving sugammadex vs. neostigmine/glyco?
I have been using sugammadex as the reversing agent for most of my cases . Pros : onset time , consistently a complete reversal of the block ( when one has at least 1/4 tO4) . Cons: bradycardia , allergic reaction/cardiac complications , ESRD

[Anne McNulty]

(1) The induction dose of Succinylcholine is 1-1.5 mg /KG. The induction dose of rocuronium is 0.6-1 mg. Both of these induction meds are frequently under dosed. I use the nerve stimulator to help obtain optimal conditions for intubating. I believe in using a 5mg dose of rocuronium to defasciculate before giving Succ. I have had very few patients complain of myalgias over many years of practice. My preferred dose of Roc is 0.8 - 1 mg per kilo. It is frequently under dosed . I learned to intubate with DTC (D-tubocurare) and Succinylcholine. DTC always prevented myalgias but could give a big whopper of histamine release. I love Rocuronium but it can have allergic responses such as bronchospasm that can be very problematic. I found giving 10 mcg epi iv (baby epi) helps end that bronchospasm along with recruitment breaths , 10 cm peep albuterol and dexamethasone. (2) I use sugammadex unless a pt is in hepatic or renal failure. I have had an anaphylaxis after administering sugammadex that required a trip to SICU , intubated on epi drip. It is still my choice. I have had occasional bradycardia. I try to keep the sugammadex dose at 2 mg /kg. Glyco- Neostimine have too many side effect- Bronchoconstriction, Nausea. vomiting. code brown .bradycardia and take much too long in these times of fast turnover. Roc and sugammadex are my choices unless otherwise indicated.

[aileenm4]

dose of Sux is 1-1.5 mg/kg, we rarely use in pediatrics, rocuronium is .6-1.2 mg/kg, we use rocuronium mostly in pediatrics and this dose range is accurate
we use both sugamadex and Neostigmine in peds. Neostigmine/glyco associated with nausea, excessive glyco can cause tachycardia, not enough can cause bradycardia. I use Neostigmine on teenagers or young ladies on BCP. Sugamadex is listed as causing anaphylactic issues, wheezing, hypotension especially at larger doses. We use Sugamadex even in neonates 2-4 mg/kg doses. Rocuronium is unpredictable in babies but sugamadex is an excellent reversal agent.

[Jennifer Hannon]

Succ's induction dose is 1-2 mg /kg and Roc's is 0.6-1.2 mg/kg. I think this is the range given consistently. Our patients are large so it's usually greater than 100 succ, if succ is used, but most of the time we do 1.2mg/kg roc for RSI or stun with Remi.

Sugammadex has been used more lately in my experience because it has encapsulates and clear the paralytic with less respiratory weakness in PACU. Cons to Sugammadex would be allergies, renal issues and birth control potential inefficacy.

[Amy Swank]

1. Induction dose of sux is: 1mg/kg bolus and I also think with the overweight population, frequently underdosed. Induction dose for Rocuronium is 0.6-1mg/kg bolus RSI: 1-1.2mg/kg bolus peaking in 1-2 min Many times the dose is what is in the syringe rather that what is actually appropriate for the individual patient.

(I appreciated your detailed response Dahlia, and concur on many of your points, especially the performance pressure and not waiting long enough for peak efficacy).

2. I usually use Sugammadex as a reversal agent is superior to Neostigmine/Robinul, but not without its drawbacks. Interference with oral contraceptives and clear instructions should be given to the patient. Also, is not available at Greenspring Surgery center, so that is unfortunate. I have used Neostigmine/Robinul for may years and can usually time my muscle relaxant with this in mind, for best results.