Please, please, wait for the roc to start working :(

[J-Dubya]

(Please note this is posted in the passing gas forum for a reason).

So, I'm at yet another new clinical site. Overall, it's pretty good so far. The MDAs are very hands off for the most part (I'm used as staff here). Some of them will discuss the anesthetic plan with me, but for the most part they say "it's your anesthetic do what you want." Of course, I will be held accountable for the results of the plan, but there is pretty much no hand holding.

The only thing that is bothering me has been the inductions. I was told the first day that they only give sux here if there is an indication (full stomach precautions, motor testing, etc). It wasn't clear to me if this was due to the sux shortage or just this group of practitioners' preference.

So, we have been using roc for induction (there is no vec). The induction (to jump in at the point that we are ready to go to sleep) goes as follows:

MDA pushed the prop, I give a squeeze or two on the bag and report to him that I can ventilate. He then (without variation in terms of the dose) pushes 50mg of roc. Out of habit, I always look at my watch when the roc goes it. Then what happens is the MDA stares at me and then says " well, take a look." This is happening between 40-90secs (one time I remember thinking that even if we were using sux that this guy was jumping the gun). These are average to large sized patients.

If I were running the show, I would ventilate the patient for three minutes before DL (this text book number has, for me, been borne out when I have put the nerve stim on patients in the past). I would redose the prop at around 2 mins (probably 50mg for an average patient).

In the past, when I have realized that the MDA was either not going to let me wait 3min or was going to let me wait 3 mins but was not going to give more prop, I have turned on the sevo at 8% and given a few big breaths before DL. BUT, this place does not have sevo (just iso and des).

So, here's my choice:

-go early (30seconds after the roc is in) and intubate with prop alone. Not a bad option at all in many patients. However some of these patients don't have super easy airways and I might actually need the paralytic (and for these patients I want my first shot to be my best shot).

-go late, what for the roc to kick in and hope enough prop is left so that the patient is not to light. I do give versed, but I don't want to rely on that for amnesia in the setting of an elective intubation. Plus I don't want my first BP after intubation to be through the roof.

Unfortunately, what I think I'm doing most of the time is splitting the difference so I'm performing a DL on a light patient without the benefit of paralysis :( As a result I've run into closed cords and struggled with a few easy airways.

Not much I can do as a student, but I still felt like venting!

[LouisiAnimal]

Kinda had the same thing happen to me yesterday. Pt for emergent ex lap, preop k+ was 5.3. Doc pushes 20 amidate and 50 roc. Literally about 30 sec later he says "see what you got". I tube him, BP goes to 200's. Did I mention he had a 5.5cm AAA?

The life of a student :(

[jwk]

There's a big difference between your estimates of 40-90 seconds, as well as 3 minutes. I rarely watch the clock, and never use a nerve stimulator to see if the patient is relaxed enough for intubation. You kinda get a feel for these things with experience, but if I was timing it, I'm probably sticking the blade in at about the 45sec mark. I'd be pulling my own hair out if I waited three minutes, and you would rarely NEED to wait that long. It's not like the roc stops working when you start intubating, and if they're not quite relaxed enough, they will be shortly. If you can see that the cords are relaxed, that's all the relaxation you'll need.

BTW, I think that pressure of 200 is due to under narcotization, not tubing too quickly.

[LouisiAnimal]

You'd be correct jwk.....I told you exactly what was given. 20 amidate, 50 roc, no narc

[J-Dubya]

There's a big difference between your estimates of 40-90 seconds, as well as 3 minutes. I rarely watch the clock, and never use a nerve stimulator to see if the patient is relaxed enough for intubation. You kinda get a feel for these things with experience, but if I was timing it, I'm probably sticking the blade in at about the 45sec mark.

Again, IME (based on using the nerve monitoring) at 45seconds the roc is doing just about nothing (this is based on 50mg of roc to patient that weight over 70kg). I also find that when mask ventilating the patient I do not "feel" anything at 45second in terms of changes in compliance. I just don't think the drug is doing much at that time. I'd rather have them just not give the roc and I'll intubate with just prop.

As a SRNA, I have intubated many people without paralytic on board, but in my student experince, "when you need it, you need it." I just don't see the harm in waiting the 3mins for the drug to kick in. Sure you need to redose the induction agent, but is that such a big deal. IMHO, it's the same as not waiting 60sec for sux.

For me, if an extra 2 mins means less chance of an airway complication, I'm all for it. However, clearly these MDAs agree with you.

[squeege]

You can lift the mask off the face and with your left hand try (or look like you are trying) to move the mandible & say "still a bit tight" "not quite relaxed" and resume bagging until you are more comfortable for your first look.

Sq

[deliciousbass]

I agree in that some people are too impatient for 50 mg roc to work effectively. I try and wait 2 min with 150-250mcg fent on board and turn on some DES if I'm concerned of recall. Your propofol dose for induction is plenty to cover you for 3 min with versed and fent on board.

[SuccsDrugs&Rocuron]

"When Your Surgeon's THE FLASH":

wanna talk about a bad day (with a cool CRNA TG), gave total 50 Roc on a 8 MINUTE LAP CHOLE! No lie--the FLASH insufflated, we gave trendelenburg, left tilt, bada bing! Done!

Holy crap batman...no twitches...um, goin' to any Mardi Gras parades?...

http://reilly2040.co.uk/blog/wp-content/uploads/2009/06/flash_rebirth6.jpg

[yoga]

Why not use the nerve stimulator to check relaxation. It is easy, handy and beats trying to make the clock go faster. I routinely intubate with cisatracurium (Nimbex) for my own reasons (no histamine release and nice to have extra relaxation time) and it is a slow onset muscle relaxant. So I wait the required time and intubate without problems. So glad I am working alone.

[Skeebum]

122636
In the past, when I have realized that the MDA was either not going to let me wait 3min or was going to let me wait 3 mins but was not going to give more prop, I have turned on the sevo at 8% and given a few big breaths before DL. BUT, this place does not have sevo (just iso and des).

OK, I'm with ya, intubating 3 minutes after Prop induction ............a little bump isn't a bad idea. But why not turn on the Des?? I'm willing to bet that you have placed an LMA after 200mg of prop and then turned on the Des. Yes??

As I read this my first thought was................ohhhhh, he's in the "mask induction" box. Yes you are in the process of inducing your patient, and yes Sevo is the preferred VA for mask inductions. Your patient is already induced (thanks to the Prop), you're maintaining. No contraindication comes to mind for using either VA (Des or Iso) while waiting for the Roc to kick in.

I think your 3 minute masking is a tad long, I've found that 90sec gets the job done.

ETA: Not hating the 3 minute mask: if the airway is good, ventilation in maintained, there are no containdications to masking, and you believe that is the best course of action..........Roc on (pun intended).

Just my 0.02

Skee

[RAYMAN]

All good advice. I do pretty much like jwk. With narcs and at least 100mg of milk of anesthesia, you got a good 5 minutes of amnesia, unless they are a youngster or very robust. One tip for ya John, if you feel you need to mask a little longer try chatting him up....gets his mind off things, you get the time you need plus you seem ultra smooth by carrying on a conversation about the kids, AI, sports, etc while inducing the patient.

[J-Dubya]

Thanks for all the tips guys, very helpful!

[LouisiAnimal]

Good advice skee

[pdsr]

I'd agree with adding some Des while checking the ability to mask vent. It'll help blunt the response a little, and if you let enough leak out of the mask, it may make the doc amnestic. I'd say that the doc's you're with just don't want to be bothered with thinking, or with knowing anything about the pt or the procedure. Hard to make any impact on that as a student -- Good time to study the extremes of pt response, metabolism, recovery, etc. I have the advantage of being from Texas, so people expect me to move and talk slowly, so its easier for me to get away with delaying things without it being obvious.

I always use a nerve stimulator during induction with a non-depolarizer. Its instructive, not every pt responds the same, and it gives you something to do while you're waiting. Docs are usually in a hurry just because they want to get out of the room. Glad I no longer have to deal with it.

[BigMAC - Army]

JW. Had similar experience at a place that uses only Roc or Vec for induction. Except the MDA watched me attempt to intubate too early, I could not get good view, jaw tight. Had me mask some more, wait a minute then try, better view, cords relaxed. Told me he wanted me to learn on my own and by experience that when using Roc is generally better to wait about 2 or 3 minute for better relaxation.

[iceemike1]

OK, I'm with ya, intubating 3 minutes after Prop induction ............a little bump isn't a bad idea. But why not turn on the Des?? I'm willing to bet that you have placed an LMA after 200mg of prop and then turned on the Des. Yes??

As I read this my first thought was................ohhhhh, he's in the "mask induction" box. Yes you are in the process of inducing your patient, and yes Sevo is the preferred VA for mask inductions. Your patient is already induced (thanks to the Prop), you're maintaining. No contraindication comes to mind for using either VA (Des or Iso) while waiting for the Roc to kick in.

I think your 3 minute masking is a tad long, I've found that 90sec gets the job done.ETA: Not hating the 3 minute mask: if the airway is good, ventilation in maintained, there are no containdications to masking, and you believe that is the best course of action..........Roc on (pun intended).

Just my 0.02

Skee

Agree although if these are truly "good" size pts, I'd say 90-120 seconds as you probably aren't even giving 0.6 mg/kg.

I would definitely turn on some gas--although I'd just turn on the iso.

[J-Dubya]

For dosing due to the weight of these patient, 50mg tends to be 0.5-.07mg/kg.

As I posted, I've always had sevo to reach for and I was worried that I be scolded for using something as irritating as des, didn't even consider iso to be honest. Guess they are both options???

[bettermj]

As I posted, I've always had sevo to reach for and I was worried that I be scolded for using something as irritating as des, didn't even consider iso to be honest. Guess they are both options???

I've used them all in this manner.

[jwk]

Again, IME (based on using the nerve monitoring) at 45seconds the roc is doing just about nothing (this is based on 50mg of roc to patient that weight over 70kg). I also find that when mask ventilating the patient I do not "feel" anything at 45second in terms of changes in compliance. I just don't think the drug is doing much at that time. I'd rather have them just not give the roc and I'll intubate with just prop.

As a SRNA, I have intubated many people without paralytic on board, but in my student experince, "when you need it, you need it." I just don't see the harm in waiting the 3mins for the drug to kick in. Sure you need to redose the induction agent, but is that such a big deal. IMHO, it's the same as not waiting 60sec for sux.

For me, if an extra 2 mins means less chance of an airway complication, I'm all for it. However, clearly these MDAs agree with you.


You can lift the mask off the face and with your left hand try (or look like you are trying) to move the mandible & say "still a bit tight" "not quite relaxed" and resume bagging until you are more comfortable for your first look.

Sq

Like I said - a lot of this will come with experience. Private practice folks tend not to wait around for "ideal intubating conditions". Patients don't need to be at 0/4 to be ready to intubate.

Like SDR indicated, some surgeons are REALLY fast. For those docs/procedures, we tend to go light on the roc to begin with, so you'll never be at 0/4 twitches at any point between induction and extubation. I do plenty of lap appy/lap chole cases on 70kg patients with 25-30mg of roc tops. I've been at one ASC that could whip out 8-10 laparoscopies by noon. If I shave off just a couple minutes off each case, I've saved 20 minutes, and in a busy center, they're going to be patting me on the back.

[J-Dubya]

Like I said - a lot of this will come with experience. Private practice folks tend not to wait around for "ideal intubating conditions". Patients don't need to be at 0/4 to be ready to intubate.

Like SDR indicated, some surgeons are REALLY fast. For those docs/procedures, we tend to go light on the roc to begin with, so you'll never be at 0/4 twitches at any point between induction and extubation. I do plenty of lap appy/lap chole cases on 70kg patients with 25-30mg of roc tops. I've been at one ASC that could whip out 8-10 laparoscopies by noon. If I shave off just a couple minutes off each case, I've saved 20 minutes, and in a busy center, they're going to be patting me on the back.

I've trained in that envirnoment as well (15min lap choles), I know plenty of people that give 20 or 30mg of roc to intubate.

But, for me, (and this might change with experince), I just use sux for intubating these patients in that envriment (and then a low dose of NDMR for surgical relaxation). I think it's safer and I'm more comfortable with it. Again, I know that many people can be intubated with any paralysis (and I have done a lot of these intubations), but for me, I like to give sux in this setting.

[MmacFN]

in 40-90 seconds the average patient wont be paralyzed well enough for intubation and wont be at the optimal conditions for intubation (which is dangerous).

To me this is a blatant disregard for the pharmacokinetics and dynamics of the drug with an unreasonable expectation.

Now, can you put the blade in? Sure but the second you pass the tube they will buck like crazy. It is neither smooth or the right thing to do.

Sometimes you learn what NOT to do in clinical..


(Please note this is posted in the passing gas forum for a reason).

So, I'm at yet another new clinical site. Overall, it's pretty good so far. The MDAs are very hands off for the most part (I'm used as staff here). Some of them will discuss the anesthetic plan with me, but for the most part they say "it's your anesthetic do what you want." Of course, I will be held accountable for the results of the plan, but there is pretty much no hand holding.

The only thing that is bothering me has been the inductions. I was told the first day that they only give sux here if there is an indication (full stomach precautions, motor testing, etc). It wasn't clear to me if this was due to the sux shortage or just this group of practitioners' preference.

So, we have been using roc for induction (there is no vec). The induction (to jump in at the point that we are ready to go to sleep) goes as follows:

MDA pushed the prop, I give a squeeze or two on the bag and report to him that I can ventilate. He then (without variation in terms of the dose) pushes 50mg of roc. Out of habit, I always look at my watch when the roc goes it. Then what happens is the MDA stares at me and then says " well, take a look." This is happening between 40-90secs (one time I remember thinking that even if we were using sux that this guy was jumping the gun). These are average to large sized patients.

If I were running the show, I would ventilate the patient for three minutes before DL (this text book number has, for me, been borne out when I have put the nerve stim on patients in the past). I would redose the prop at around 2 mins (probably 50mg for an average patient).

In the past, when I have realized that the MDA was either not going to let me wait 3min or was going to let me wait 3 mins but was not going to give more prop, I have turned on the sevo at 8% and given a few big breaths before DL. BUT, this place does not have sevo (just iso and des).

So, here's my choice:

-go early (30seconds after the roc is in) and intubate with prop alone. Not a bad option at all in many patients. However some of these patients don't have super easy airways and I might actually need the paralytic (and for these patients I want my first shot to be my best shot).

-go late, what for the roc to kick in and hope enough prop is left so that the patient is not to light. I do give versed, but I don't want to rely on that for amnesia in the setting of an elective intubation. Plus I don't want my first BP after intubation to be through the roof.

Unfortunately, what I think I'm doing most of the time is splitting the difference so I'm performing a DL on a light patient without the benefit of paralysis :( As a result I've run into closed cords and struggled with a few easy airways.

Not much I can do as a student, but I still felt like venting!

[m_playman]

Is sux an option for you at this site? Seems like a better fit all around considering your staff is wanting Roc to behave as Sux in those conditions.

[Skeebum]

I've used them all in this manner.

Agree.

Although I would tend to turn on the Sevo also, (I totally see where you are coming from J-dub), I don't think you should be concerned with one Vs. the other. I would have no worries spinning the "purple" or the "blue" (given the scenario you described).

[anesthesiaMD]

A full 90 seconds should allow good intubating conditions for rocuronium. You can always give a priming dose up front if you want to speed things along. If it's a short case, then I use sux and a small amount of depolarizer afterwards (as mentioned above, you won't get burned at the end of the case). Sounds like your colleague just got a little impatient.

[jwk]

in 40-90 seconds the average patient wont be paralyzed well enough for intubation and wont be at the optimal conditions for intubation (which is dangerous).

To me this is a blatant disregard for the pharmacokinetics and dynamics of the drug with an unreasonable expectation.

Now, can you put the blade in? Sure but the second you pass the tube they will buck like crazy. It is neither smooth or the right thing to do.

Sometimes you learn what NOT to do in clinical..

Again - you don't need optimal conditions to intubate every patient. There are lots of ways to avoid bucking besides waiting to knock out all your twitches. Lidocaine IV, narcotics, LTA's, crank up the agent, etc. There are lots of "right ways" to do just about everything.

[aero]

A full 90 seconds should allow good intubating conditions for rocuronium. You can always give a priming dose up front if you want to speed things along. If it's a short case, then I use sux and a small amount of depolarizer afterwards (as mentioned above, you won't get burned at the end of the case). Sounds like your colleague just got a little impatient.

I'm assuming you meant non-depolarizer...

[anesthesiaMD]

Yes. I meant to type non depolarizer. Thanks for the correction.

[bettermj]

A full 90 seconds should allow good intubating conditions for rocuronium. You can always give a priming dose up front if you want to speed things along. If it's a short case, then I use sux and a small amount of depolarizer afterwards (as mentioned above, you won't get burned at the end of the case). Sounds like your colleague just got a little impatient.

When I first started working on my own, I forgot how bad Roc burns..... I mix mine with 4 ccs of lido (instead of with my dip). Keeps the patient from making death threats as I'm trying to put them to sleep. lol

[jagger67]

A little Ketamine works well for burning of Propofol, Roc, Benadryl...plus added effect of NMDA receptor activity.

[RAYMAN]

When I first started working on my own, I forgot how bad Roc burns..... I mix mine with 4 ccs of lido (instead of with my dip). Keeps the patient from making death threats as I'm trying to put them to sleep. lol

If you give propofol first they won't notice the roc burning. ;)

[bettermj]

If you give propofol first they won't notice the roc burning. ;)

Yeah, but I learned to push the defasic dose 1st to give it enough time to do its job. So I give versed/zofran as they slide on table, then roc/lido.... Fent, dip, ventilate, then sux. The time bw the roc & sux is usually sufficient enough to be effective. Am I missing something obvious?


Sent from my iPhone using GasTalk

[ljcubed]

I found this thread interesting, and odd. I obtain intubating conditions with Roc within a minute most of the time. Onset to tracheal intubation is 1 minute with Roc at 50 mg, any patient under 90 kg should be ready, and most over 90 will be. The propofol and fentanyl provide enough of a base that if I go a little longer I am not concerned. On the other hand, I work with these anesthetic gases EVERY day, I try to limit my (and my co-workers) exposure, I will give a second dose of propofol rather than turn on the gas. But I very rarely have to do that.
Pharmacodynamics of Rocuronium:
http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=13934#nlm34068-7

[J-Dubya]

I found this thread interesting, and odd. I obtain intubating conditions with Roc within a minute most of the time. Onset to tracheal intubation is 1 minute with Roc at 50 mg, any patient under 90 kg should be ready, and most over 90 will be.

That has's not been my experience based on using the nerve stimiulator. 50mg of roc in a 90kg patient is as fast as sux (60seconds), I'm just not seeing it, but maybe.....

In terms giving a patient a couple of breaths of PIA to deepen then - I don't really worry too much about the small amount of gas that may leak in the environment. I try to minimize it (good seal, turn it off when I take the mask off), but after spending time in a pedi hospital, I don't think a little bit of trace gas in this situations really compares with doing full on mask inductions day in and day out.

[ethernaut]

In terms giving a patient a couple of breaths of PIA to deepen then - I don't really worry too much about the small amount of gas that may leak in the environment. I try to minimize it (good seal, turn it off when I take the mask off), but after spending time in a pedi hospital, I don't think a little bit of trace gas in this situations really compares with doing full on mask inductions day in and day out.

based on the scavenging systems we have today, and the air exchanges that occur every six minutes or so, really makes the "worrisome" ppm's essentially benign.

[J-Dubya]

based on the scavenging systems we have today, and the air exchanges that occur every six minutes or so, really makes the "worrisome" ppm's essentially benign.

Yup, my point exactly

[MmacFN]

Hey LJ

Next time you use rocc put the nerve stim on and see how long it takes for twitches to go away. Its usually over 90 seconds with any dose of rocc. However its under 40 with suxx. I just tube everyone with suxx and its a non-issue.


I found this thread interesting, and odd. I obtain intubating conditions with Roc within a minute most of the time. Onset to tracheal intubation is 1 minute with Roc at 50 mg, any patient under 90 kg should be ready, and most over 90 will be. The propofol and fentanyl provide enough of a base that if I go a little longer I am not concerned. On the other hand, I work with these anesthetic gases EVERY day, I try to limit my (and my co-workers) exposure, I will give a second dose of propofol rather than turn on the gas. But I very rarely have to do that.
Pharmacodynamics of Rocuronium:
http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=13934#nlm34068-7

[RAYMAN]

Hey LJ

Next time you use rocc put the nerve stim on and see how long it takes for twitches to go away. Its usually over 90 seconds with any dose of rocc. However its under 40 with suxx. I just tube everyone with suxx and its a non-issue.

Hey Mike, you ever have any issues with myalgias?

[bettermj]

Hey Mike, you ever have any issues with myalgias?

She's on this site, isn't she?

.....

ok, it was a corny joke.

[MmacFN]

Nope.


Hey Mike, you ever have any issues with myalgias?

[armygas]

Hey Mike, you ever have any issues with myalgias?

Nope, me either......


The Sprint Epic Rocks!!

[bettermj]

Nope, me either......


The Sprint Epic Rocks!!
Mike/Army,

Do you use a defascic dose? And if so, how long before you push the sux?

Thanks

[MmacFN]

I generally do not use a defas dose of anything. I have found that half the time it does not work at all and the other half the pt feels weakness that disturbs them. It isnt worth it to me for them to feel that way. If you do it correctly its 10% of the standard NDMB dose 5-7 minutes BEFORE you plan to give suxx. It seems to me most of the time ive tried it 10% dose of Rocc does not work at all and 10% dose of vecc is variable.

So, IMHO the risks of the patient having the feeling they cannot breathe or are weak all the sudden isnt worth it to me to do. On top of that, ive YET to see a single suxx myalgia on any age pt ive taken care of (and i use ALOT of suxx)



Mike/Army,

Do you use a defascic dose? And if so, how long before you push the sux?

Thanks

[bettermj]

I generally do not use a defas dose of anything. I have found that half the time it does not work at all and the other half the pt feels weakness that disturbs them. It isnt worth it to me for them to feel that way. If you do it correctly its 10% of the standard NDMB dose 5-7 minutes BEFORE you plan to give suxx. It seems to me most of the time ive tried it 10% dose of Rocc does not work at all and 10% dose of vecc is variable.

So, IMHO the risks of the patient having the feeling they cannot breathe or are weak all the sudden isnt worth it to me to do. On top of that, ive YET to see a single suxx myalgia on any age pt ive taken care of (and i use ALOT of suxx)

Gonna try it without for a few weeks and see for myself. Thanks!


Sent from my iPhone using GasTalk

[ethernaut]

I can't find any studie(s) that actually show(s) that a defasciculating dose decreases post-op myalgia. what it apparently does is decrease the amount if fasciculations, and that's it. so, (pre)treat as personally necessary is my thought.

[skipaway]

Due to the sux shortage in our area, I've stopped using defasciculating doses of Roc. The doseage of sux is increased in this situation. I have not had an increase in the number of patients complaining of post-op myalgias.

[bettermj]

Due to the sux shortage in our area, I've stopped using defasciculating doses of Roc. The doseage of sux is increased in this situation. I have not had an increase in the number of patients complaining of post-op myalgias.

Tried it today without the roc. Young nursing student observed the fasciculations and I showed her these posts. Now she is a fan of skip and ether and wants to be a Crna. Plus I had to convince her I wasn't doing Facebook.


Sent from my iPhone using GasTalk

[airsnooze]

Two person inductions are dangerous. It simply strokes the MDA ego and denegrates the CRNA SRNA. Its done with purpose. Only the Induction person can
tell if airways are patent, dooable, intubatable, light, deep, whatever. If a MDA needs to stand over a CRNA for induction, they have the wrong CRNA doing
anesthesia ! Its like two people using a ambu bag. How does the person pressing the bag tell the person holding the mask that its leaking, good , bad, obstructed,
or needs to press harder, softer, etc. If you can't bag a patient by yourself, your dangerous in this setting. CRNA's are working all over the USA in hospitals, Surgi-centers, offices, without MDA supervison. Now we have to have a doctorate to do a simple case, and Paramedics, yes firemen are giving and pushing Diprovan
fentanyl, Versed, etc in dental offices, GI clinics. Its a fight for turf never forget it.

[Anthony]

Yes... not commonly though... but of the ones that have commented/complained - they tend to be obese and or out of shape...


...you ever have any issues with myalgias?

[anesthesiaMD]

There is no definitive evidence that pretreatment prevents post-op sux myalgias (if such a thing exists at all). The problem seems to be multifactorial. Here's a meta-analysis from Anesthesiology. Interestingly, the authors concluded that lidocaine and NSAID's may be more effective than a nondepolarizer. In training, most of our patients received Pentothal/sux and did fine. More importantly, one has to think about weakness induced by pretreatment, prolonged paralysis (vs. sux alone) and an increased sux dose in a time of shortage.

http://journals.lww.com/anesthesiology/Fulltext/2005/10000/Prevention_of_Succinylcholine_induced.27.aspx

[RAYMAN]

I know that there is no definitive tx for myalgias but haven't read/remember any actual incidence. Every place always seems to have at least one provider who hates Sux because they've seen or experienced myalgias personally. I love the stuff, just curious and most folks experience.

[J-Dubya]

My first four months as student I trained at a trauma center where we always used sux. As part of our program (I'm sure most programs) I made post-op visits and never hand complaints of myalgias. However, it's one of those subject that people love to get to up on their high horses over "You didn't roc first, you must not care about your patients!"

If I could do my own thing (at this point in my training) I'd use sux for everyone (unless contraindicated). I'm one of those students that is secretly loving the neostig shortage :)

[ethernaut]

Tried it today without the roc. Young nursing student observed the fasciculations and I showed her these posts. Now she is a fan of skip and ether and wants to be a Crna. Plus I had to convince her I wasn't doing Facebook.


Sent from my iPhone using GasTalk
dang!

[armygas]

Mike/Army,

Do you use a defascic dose? And if so, how long before you push the sux?

Thanks

Never ever used a defas dose.......

Sent from my nookcolor

[armygas]

There is no definitive evidence that pretreatment prevents post-op sux myalgias (if such a thing exists at all). The problem seems to be multifactorial. Here's a meta-analysis from Anesthesiology. Interestingly, the authors concluded that lidocaine and NSAID's may be more effective than a nondepolarizer. In training, most of our patients received Pentothal/sux and did fine. More importantly, one has to think about weakness induced by pretreatment, prolonged paralysis (vs. sux alone) and an increased sux dose in a time of shortage.

http://journals.lww.com/anesthesiology/Fulltext/2005/10000/Prevention_of_Succinylcholine_induced.27.aspx
I will add that I give 1-1.5 mg/kg to everyone preinduction.


Sent from my nookcolor

[jwk]

Anyone ever used a small dose of sux for defasciculation?

[armygas]

Anyone ever used a small dose of sux for defasciculation?

You mean a taming dose ;)

Sent from my nookcolor

[J-Dubya]

You mean a taming dose ;)

Sent from my nookcolor

MDA I was with yesterday gave a taming dose, pt. still fasiculated.

[RAYMAN]

Anyone ever used a small dose of sux for defasciculation?

Yap...also great for when you can't get a lma to seat and the patient starts spitting and sputtering. 20 mg and you are usually golden.

[caind44]

Anyone ever used a small dose of sux for defasciculation?

Nope but I've used a larger dose. In school we used to give average sized patients 200 mg. If over 100 kg they got 300 mg. I can't speak to the mechanism of action but the patients rarely fasiculated. One of the MDAs showed me a paper on this but I can't recall any specifics.

[RAYMAN]

Nope but I've used a larger dose. In school we used to give average sized patients 200 mg. If over 100 kg they got 300 mg. I can't speak to the mechanism of action but the patients rarely fasiculated. One of the MDAs showed me a paper on this but I can't recall any specifics.

Maybe instead of the nmj firing repeatedly, it's just one big grand mal

[bettermj]

dang!

she said she could tell you were hot by your Avatar. I told her as soon as she graduates, she can look you up because you ain't payin' no tuition.

[goingtogooding]

Literature (and my brief experience) supports that concentrations less than 1 MAC of either desflurane or isoflurane do not contribute to coughing, etc. Bag them with a little desflrane. Perhaps a "priming dose" of roc (1/10th intubation dose) prior to lido/prop will hasten your onset to ~45 seconds. This seems to work well.

[ethernaut]

she said she could tell you were hot by your Avatar. I told her as soon as she graduates, she can look you up because you ain't payin' no tuition.
well, if she's anything like supersleeper, you can send her my way!

[bettermj]

well, if she's anything like supersleeper, you can send her my way!

Not even close!!!

[ethernaut]

Not even close!!!

butter?

[bettermj]

butter?

yep