sugammadex

[chaz90]

Cool. Any experience using it yet?


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[Summit]

Nothing yet. Just got notice today. (this is in-hospital formulary)

 

[Nova1300]

I wanted so badly to hate on this drug. Hoping it would not to work because it seems so much like cheating.

But it does work. Really well. With no noticeable side effects, at least the few times I have seen it given. I have watched a complete dense neuromuscular blockade with 0/4 twitches on TOF transition to a brisk 4 full twitches in about 60 seconds after a single dose. Then pulling 750 ml tidal volumes within the next minute with no change in vital signs whatsoever. It was pretty beautiful to watch, honestly.

However, none of these cases were emergencies either. That's where I'm curious about this drug. Is it actually useful to reverse NMB in an emergency situation? Or are you only making a bad situation worse?

 

[Summit]

However, none of these cases were emergencies either. That's where I'm curious about this drug. Is it actually useful to reverse NMB in an emergency situation? Or are you only making a bad situation worse?

I think that depends on the patient, the emergency, why they were paralyzed, and why you need to emergent reverse. Was it a drug error?

 

[Nova1300]

I think that depends on the patient, the emergency, why they were paralyzed, and why you need to emergent reverse. Was it a drug error?

I guess that's the point I'm making here. I can't see a lot of clinical utility for NMB reversal in the emergency setting, especially in the case of a failed airway after multiple attempts have been made.

In the heat of an airway emergency, are we going to get sidetracked trying to salvage a hypoxic patient with NMB reversal instead of moving onto the next step of the airway algorithm?

I'm always shocked at the lengths people will go to and the patient hypoxia they will tolerate in order to avoid a surgical airway. I'm worried NMB reversal agents will be one more thing to keep us distracted when we should be preparing for a surgical airway.

But, I'm also paranoid about everything shiny and new.

 

[Summit]

I think the primary use is not as a rescue drug, but to speed up wakeup/extubation and thus reduce complications and shorten visits.

 

[TransportJockey]

Or to help with, say, paralyzed and intubated stroke patients to help the neurologist get a better assessment quicker

 

[TXmed]

I guess that's the point I'm making here. I can't see a lot of clinical utility for NMB reversal in the emergency setting, especially in the case of a failed airway after multiple attempts have been made.

In the heat of an airway emergency, are we going to get sidetracked trying to salvage a hypoxic patient with NMB reversal instead of moving onto the next step of the airway algorithm?

I'm always shocked at the lengths people will go to and the patient hypoxia they will tolerate in order to avoid a surgical airway. I'm worried NMB reversal agents will be one more thing to keep us distracted when we should be preparing for a surgical airway.

But, I'm also paranoid about everything shiny and new.

I fully agree with you there sir.

 

[Nova1300]

I think the primary use is not as a rescue drug, but to speed up wakeup/extubation and thus reduce complications and shorten visits.

And that is exactly why I question its use in an emergency setting. When you said your hospital got it on formulary, is it strictly for use in intraoperative anesthesia?

 

[Carlos Danger]

I wanted so badly to hate on this drug. Hoping it would not to work because it seems so much like cheating.
But it does work. Really well. With no noticeable side effects, at least the few times I have seen it given.

I feel the same way. Part of me wanted badly for it to suck for some reason. But from what I have heard it is the cat's meow. Haven't seen it yet myself.

I am surprised to see it so broadly adopted, so quickly. Very often these new things are cost prohibitive (compared to their alternatives) while they are on patent. I wonder if the manufacturers of neostigmine are kicking themselves for jacking the price of it up so much a few years ago. They made more money for a few years, but are now losing market share rapidly. If they hadn't done so, I bet suggamadex would still be something that we've all heard about and would love to use, but which many of us can't get our pharmacies to stock due to cost. Very much like dexmedetomidine.

I guess that's the point I'm making here. I can't see a lot of clinical utility for NMB reversal in the emergency setting, especially in the case of a failed airway after multiple attempts have been made.

In the heat of an airway emergency, are we going to get sidetracked trying to salvage a hypoxic patient with NMB reversal instead of moving onto the next step of the airway algorithm?

I'm always shocked at the lengths people will go to and the patient hypoxia they will tolerate in order to avoid a surgical airway. I'm worried NMB reversal agents will be one more thing to keep us distracted when we should be preparing for a surgical airway.

But, I'm also paranoid about everything shiny and new.

I can see some potential utility for occasional emergency reversal.....in the right hands and in specific situations. Or at least, I can conceive of scenarios where it might be useful.

IME, a large percentage - at least 50%, probably more - of RSI's done in those settings are "elective", meaning the patient was breathing and maintaining their airway just fine prior to induction. So I think the whole "it never makes sense to abandon an RSI attempt, because you haven't fixed the reason you were intubating in the first place" is not always applicable. Maybe my experience with airway management outside the OR is unique, I don't know.

The bigger problem that I see with it - I think you hit the nail on the head here - is that the possibility of reversal will be another distraction for someone who is already in over their head with an airway. It'll either be considered at too late a time, or it will be used when the best step would've been to move ahead in the algorithm.

But hey, I still prefer sux for RSI, anyway.

 

[Nova1300]

I feel the same way. Part of me wanted badly for it to suck for some reason. But from what I have heard it is the cat's meow. Haven't seen it yet myself.

I am surprised to see it so broadly adopted, so quickly. Very often these new things are cost prohibitive (compared to their alternatives) while they are on patent. I wonder if the manufacturers of neostigmine are kicking themselves for jacking the price of it up so much a few years ago. They made more money for a few years, but are now losing market share rapidly. If they hadn't done so, I bet suggamadex would still be something that we've all heard about and would love to use, but which many of us can't get our pharmacies to stock due to cost. Very much like dexmedetomidine.




I can see some potential utility for occasional emergency reversal.....in the right hands and in specific situations. Or at least, I can conceive of scenarios where it might be useful.

IME, a large percentage - at least 50%, probably more - of RSI's done in those settings are "elective", meaning the patient was breathing and maintaining their airway just fine prior to induction. So I think the whole "it never makes sense to abandon an RSI attempt, because you haven't fixed the reason you were intubating in the first place" is not always applicable. Maybe my experience with airway management outside the OR is unique, I don't know.

The bigger problem that I see with it - I think you hit the nail on the head here - is that the possibility of reversal will be another distraction for someone who is already in over their head with an airway. It'll either be considered at too late a time, or it will be used when the best step would've been to move ahead in the algorithm.

But hey, I still prefer sux for RSI, anyway.

I think what I fear about this drug is that it will make its way into code carts and Pyxis machines, anywhere rocuronium is stocked. And will be viewed as a fail safe for therapeutic misadventures with muscle relaxant.

Im finding sux has become increasingly rare outside of the OR. People are scared of it. None of our ICUs will stock it and it's not on code carts. If I want to use sux, I have to call down to pharmacy, put in an order and wait for it to come up the tube. 45 vials of rocuronium in the Pyxis at any given moment, but no Sux. Which is actually rather funny because I rarely used it when I worked in the OR, but would love to have access to it in the ICU.


But back to this new contraption- I think the manufacturer should make it very clear that this is a drug developed and studied in intraoperative anesthesia to reverse muscle relaxant given for surgical procedures. It was not developed for rescue during airway emergency, and I could see reasons it would actually worsen outcomes in those situations.


It must be emphasized that this stuff is not the 'narcan' of intubation.


I reiterate to people that, for now, the difficult airway algorithm is the standard of care and sugammadex is not a part of that. Once you push that roc, you are committed to that pathway. And giving sugammadex will most likely be a hindrance to other steps within the algorithm, such as placing LMA or performing surgical airway.

 

[Carlos Danger]

Im finding sux has become increasingly rare outside of the OR. People are scared of it.

We can place the blame for that largely on the shoulders of the FOAMed community, which is squarely against succinylcholine and whose leaders have a cult of personality that causes many to take as gospel anything they say. The rationale is that sux is a dirty drug with too many contraindications and side effects, and that roc is thus safer and easier to use. That's fair enough, I suppose - you certainly can make an argument for roc over sux as your routine NMB for RSI. But as you know, sux has subtle advantages that only people who use different NMB's frequently will appreciate, and it's disadvantages are dramatically overstated in the FOAMed community. To hear them talk you'd think every other emergent intubation is in a kid with undiagnosed DMD or a renal patient with a K of 7, and that it's just too complicated to remember the basic contraindications for sux. Honestly, I think lots of people who talk about how superior sux is don't have the experience to really make that judgement, and like to use it because only "hard core airway operators" use a long-lasting NMB for RSI. But at any rate, yes, the anti-sux sentiment has spread rapidly throughout the EM and EMS communities in recent years.

It must be emphasized that this stuff is not the 'narcan' of intubation.

You know it is only a matter of time before you hear someone say that, lol.

 

[Nova1300]

We can place the blame for that largely on the shoulders of the FOAMed community, which is squarely against succinylcholine and whose leaders have a cult of personality that causes many to take as gospel anything they say. The rationale is that sux is a dirty drug with too many contraindications and side effects, and that roc is thus safer and easier to use. That's fair enough, I suppose - you certainly can make an argument for roc over sux as your routine NMB for RSI. But as you know, sux has subtle advantages that only people who use different NMB's frequently will appreciate, and it's disadvantages are dramatically overstated in the FOAMed community. To hear them talk you'd think every other emergent intubation is in a kid with undiagnosed DMD or a renal patient with a K of 7, and that it's just too complicated to remember the basic contraindications for sux. Honestly, I think lots of people who talk about how superior sux is don't have the experience to really make that judgement, and like to use it because only "hard core airway operators" use a long-lasting NMB for RSI. But at any rate, yes, the anti-sux sentiment has spread rapidly throughout the EM and EMS communities in recent years.




You know it is only a matter of time before you hear someone say that, lol.

What's really nuts about the whole thing is that its 2016 and we still don't have a rapid-onset and ultra short-acting, non-depolarizing paralytic available on the market. As far as I know, mivacurium was the last attempt. But it wasn't ideal either.

its not like it wouldn't be a cash cow. They would stock it everywhere.

 

[Carlos Danger]

What's really nuts about the whole thing is that its 2016 and we still don't have a rapid-onset and ultra short-acting, non-depolarizing paralytic available on the market. As far as I know, mivacurium was the last attempt. But it wasn't ideal either.

its not like it wouldn't be a cash cow. They would stock it everywhere.

Right......that is where the money is.

I never used mivacurium. I wonder why the anti-sux crowd isn't more excited about Nimbex. At least as fast onset as roc, from what I understand. I've only used it a handful of times and never the RSI dose.