Sugammadex now recommended per ASA

[linkin06]

2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade

These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents during and after general anesthesia. The guidance focuses primarily on the type and site of monitoring and the process of antagonizing...

pubs.asahq.org

Sugammadex is recommended from deep, moderate, and shallow levels of neuromuscular blockade that is induced by rocuronium or vecuronium. Neostigmine is a reasonable alternative from minimal blockade (train-of-four ratio in the range of 0.4 to less than 0.9). Patients with adequate spontaneous recovery to train-of-four ratio greater than or equal to 0.9 can be identified with quantitative monitoring, and these patients do not require pharmacological antagonism.

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[abolt18]

Recommended, not standard of care.

"Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome."

 

[linkin06]

Recommended, not standard of care.

"Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome."

Sounds like typical CYA. But at least some leverage if pharmacy pushes back

 

[UscGhost]

It's significantly faster and more predictable than neostigmine. Also allows for reversal of a deeper block.

I really see no advantage to using neostigmine over sugammadex other than maybe cost? And these days... depending on your pharmacy..it's not a significant difference

 

[Twiggidy]

How deep or even shallow a blockade are we talking? I’m curious about these doses of muscle relaxant people use. Of course I’m biased because I work mostly inpatient so I’ve never felt the pressure of a fast relax/fast reverse situation.

 

[dannyboy1]

Suggamadex is a great drug. Much better than roc. Don’t need a study to tell me that.
I wonder though about the effects of deep, prolonged neuromuscular blockade. I’ve seen CRNA’s (and some docs) run roc infusions through long 6-8 hour cases just because of the availability of suggamadex. I would think that completely blocking the neuromuscular junction for that long can cause significant muscle weakness and atrophy post-op, causing problems, especially if the patient is elderly and has decreased muscle mass at baseline.

 

[Greenbayslacker]

significant muscle weakness and atrophy post-op

How so? All muscle weakness should be reversed at the end, eliminating the risk of atrophy

 

[Twiggidy]

I’ve seen CRNA’s (and some docs) run roc infusions through long 6-8 hour cases

Do they do this just because they're too lazy to draw up some roc every hour or so? Don't want surgeons complaining about "twitches'? It's actually be a while since i've had a surgeon mention twitches to me but maybe i'm not doing the right cases

 

[dannyboy1]

How so? All muscle weakness should be reversed at the end, eliminating the risk of atrophy

Completely blocking neuromuscular junction causes significant and rapid muscle wasting in the ICU setting. The same thing might happen during a long OR case with deep neuromuscular blockade. I’m not sure this happens and is significant. Just theorizing….

 

[Status Sciaticus]

Do they do this just because they're too lazy to draw up some roc every hour or so? Don't want surgeons complaining about "twitches'? It's actually be a while since i've had a surgeon mention twitches to me but maybe i'm not doing the right cases

Used to do this in residency for those 10+ hour cases. Anecdotally found that less roc was used via infusions than bolusing. Tended to resort to suggamadex a lot less. But again, anecdotal experience.

 

[agammaglobulin]

I did paralytic infusions in residency for long cases as well. It was nice not having to worry about redosing. Cis gtt for liver transplants. Roc gtt for DIEP flap.

Thinking back - maybe it was so the attendings don't have to worry about the patient moving while supervising residents?

 

[coffeebythelake]

Completely blocking neuromuscular junction causes significant and rapid muscle wasting in the ICU setting. The same thing might happen during a long OR case with deep neuromuscular blockade. I’m not sure this happens and is significant. Just theorizing….

Prolonged durations. Very prolonged.

 

[vector2]

Sounds like typical CYA. But at least some leverage if pharmacy pushes back

Yes, the pharmacy pushback part of the guideline is really the useful part. Sugammadex is not restricted at my hospital but every now and then our chief brings up some chatter from the pharmacy folks about the cost. Hopefully this will be helpful in my perpetual quest to tell the pharmacy bean counters to stfu

 

[Twiggidy]

I did paralytic infusions in residency for long cases as well. It was nice not having to worry about redosing. Cis gtt for liver transplants. Roc gtt for DIEP flap.

Thinking back - maybe it was so the attendings don't have to worry about the patient moving while supervising residents?

Ok. I can see that. I haven’t done a neck flap in forever but I do know plastics folks can be divas about the twitches. I know livers are long and unstable so I can actually see the benefit of a drip if the anesthetic has be slightly light and you don’t want the patient to move

 

[Status Sciaticus]

Ok. I can see that. I haven’t done a neck flap in forever but I do know plastics folks can be divas about the twitches. I know livers are long and unstable so I can actually see the benefit of a drip if the anesthetic has be slightly light and you don’t want the patient to move

interesting thing about livers is that since roc is largely metabolized by the liver, it will lead to prolonged paralysis from your initial bolus until the new one is perfused... which is when you want the paralytic to be eliminated.... works out quite nicely.

 

[Radetzky]

Completely blocking neuromuscular junction causes significant and rapid muscle wasting in the ICU setting. The same thing might happen during a long OR case with deep neuromuscular blockade. I’m not sure this happens and is significant. Just theorizing….

Not for an OR case.

Sugamadex has one of the highest anaphylaxis rates of any drug in anesthesia, so if I can avoid giving it unnecessarily, I will.

 

[agammaglobulin]

Not for an OR case.

Sugamadex has one of the highest anaphylaxis rates of any drug in anesthesia, so if I can avoid giving it unnecessarily, I will.

There was a study in japan (where Sugammadex has been used for a while) where it showed anaphylaxis rate about the same as Roc. I'll try to find it.

 

[UscGhost]

Not for an OR case.

Sugamadex has one of the highest anaphylaxis rates of any drug in anesthesia, so if I can avoid giving it unnecessarily, I will.

Anaphylaxis risk likely overrated

This study showed 19 cases out of 1.5 million and all recovered.

Residual paralysis from roc plus neostigmine likely causes more harm overall.

Estimated Incidence of Sugammadex-Induced Anaphylaxis Using the Korea Adverse Event Reporting System Database

We aimed to investigate the incidence of sugammadex-induced anaphylaxis in a large Korean population. We retrospectively investigated the incidence of sugammadex-induced anaphylaxis between 2013 and 2019 from the database of the Korea Institute of Drug Safety-Risk Management-Korea Adverse Event...

www.mdpi.com

 

[agammaglobulin]

Sugammadex: The Anaphylactic Risk. From the Anesthesia Patient Safety Foundation. It references the study i was referring to.

"If one estimates the actual anaphylactic rate to sugammadex as roughly similar to that of rocuronium as referenced by Takazawa et al., then with the increased usage of sugammadex, we could estimate that the total incidence of intraoperative anaphylactic events will increase by at least one-third. If the current rate of intraoperative anaphylaxis is 1:10-20,000, it might increase to 1:6-14,000"

 

[deleted875186]

My two cents.

Deep neuromuscular blockade helps with certain surgeries. I use deep blockade in most lap cases because there’s some evidence it decreases pain. With neostigmine it’s hard to do with a fast surgeon. Suggamadex makes it possible.

I hate when people give too much roc, it’s just lazy. Many cases can be done with minimal redosing of paralytic. That being said I did some infusions in residency, for a predictably long case it works fine.

 

[Beeftenderloin]

Do they do this just because they're too lazy to draw up some roc every hour or so? Don't want surgeons complaining about "twitches'? It's actually be a while since i've had a surgeon mention twitches to me but maybe i'm not doing the right cases

In residency it felt like hearing an exasperated surgeon ask me if I’m sure the patient has zero twitches was a near daily occurrence. 6 months into my current job and I could prob count on 1 hand the number of times a surgeon has said anything about NMB.

 

[dabears505]

Any drug that requires you to give another drug in combination because of its horrible side effects is trash. Neostigmine was used because there was no real alternative. Suggamadex should be declared standard of care.

 

[Dr. Rude]

The reality is that if cost were not an issue, we would use suggamadex like water and folks would be saying"what is neostigtme?"

 

[aneftp]

The OP needs to change the title. “Standard of care” for anesthesia vs recommended (aka grey areas subject to interpretation)

The last “standard of care” published by the ASA was the use of end tidal co2 during moderate and deep sedation cases in 2011

The Latest ASA Mandate: CO2 Monitoring For Moderate and Deep Sedation

www.ncbi.nlm.nih.gov

Prior to that it was almost 30 years (early 1980s) when then ASA last publish a new “standard of care”

There are extremely few “standard of care” changes in anesthesia. So let’s not overuse the term.

Even ultrasound use for lines isn’t “standard” of care. One of the docs in my practice is old time and still does lines without use of ultrasound. I know Medicare won’t pay for complications with lines if ultrasound isn’t used. But ultrasound is not a “standard” either. So if they get sued for complication. A rookie lawyer would look foolish if they spoke this doc “violated the standard of care”. They did not.

So bridion is not the standard for reversal. And yes. Allergic reactions do occur. I just witness another one earlier this week on Asa 4.75 patient bp was stable than end of the case gave it and bp when to the 40s after 60 seconds given of bridion. The patient was stable prior to given the drug. Breathing on their own.

 

[1halfMVsquared]

Can an admin edit the title of this thread for its incorrectness?

 

[deleted1147063]

Can an admin edit the title of this thread for its incorrectness?

No, because it's not of the political kind.

 

[Gas you down]

The OP needs to change the title. “Standard of care” for anesthesia vs recommended (aka grey areas subject to interpretation)

The last “standard of care” published by the ASA was the use of end tidal co2 during moderate and deep sedation cases in 2011

The Latest ASA Mandate: CO2 Monitoring For Moderate and Deep Sedation

www.ncbi.nlm.nih.gov

Prior to that it was almost 30 years (early 1980s) when then ASA last publish a new “standard of care”

There are extremely few “standard of care” changes in anesthesia. So let’s not overuse the term.

Even ultrasound use for lines isn’t “standard” of care. One of the docs in my practice is old time and still does lines without use of ultrasound. I know Medicare won’t pay for complications with lines if ultrasound isn’t used. But ultrasound is not a “standard” either. So if they get sued for complication. A rookie lawyer would look foolish if they spoke this doc “violated the standard of care”. They did not.

So bridion is not the standard for reversal. And yes. Allergic reactions do occur. I just witness another one earlier this week on Asa 4.75 patient bp was stable than end of the case gave it and bp when to the 40s after 60 seconds given of bridion. The patient was stable prior to given the drug. Breathing on their own.

not paying for complications if you don’t use U/S is a bit crazy. Is this a blanket statement? You could either use/not use US and still put in the wire too far and have arrhythmia. Unless you also drop in TEE. But cmon not every Pt can get one
I only whine bc I hate using it. IMHO some of us have grown too dependent on it. In a trauma, not always feasible.
Really enjoyed your post btw

 

[deleted1147063]

I am not a lawyer, but... in my understanding, the ASA does not define the standard of care. Nobody specific does. We all do, together, by the way we practice.

The standard of care is what most reasonable doctors would have done in the same situation. So if most of us use sux or roc for RSI, that's the standard of care. If most of us would use EtCO2 for every moderate/deep sedation case, that's the standard of care. If most of us use U/S for blocks, that's the standard of care.

Not because the ASA, the ABA or God say it.

 

[Chief's Pineapple]

Yes, the pharmacy pushback part of the guideline is really the useful part. Sugammadex is not restricted at my hospital but every now and then our chief brings up some chatter from the pharmacy folks about the cost. Hopefully this will be helpful in my perpetual quest to tell the pharmacy bean counters to stfu

It's restricted in ours. The nurse has to leave the room to get it from the Omnicell. They also have to type in the name of the anesthesiologist (why?) who's requesting the drug, and choose one of four options as to the reason why it's being pulled.

Sometimes it's out, so they have to then go to PACU and hope it's in theirs.

 

[drmwvr]

Suggamadex is a great drug. Much better than roc. Don’t need a study to tell me that.
I wonder though about the effects of deep, prolonged neuromuscular blockade. I’ve seen CRNA’s (and some docs) run roc infusions through long 6-8 hour cases just because of the availability of suggamadex. I would think that completely blocking the neuromuscular junction for that long can cause significant muscle weakness and atrophy post-op, causing problems, especially if the patient is elderly and has decreased muscle mass at baseline.

at my place roc infusions are just dumb because of the unpredictability of duration between vials of the stuff. Depending on how long its been out of the fridge, how long it lasts is a crap shoot. Suspect it would be the same anywhere. Now a vec infusion where you can reliably dial in a single twitch for hours on end is a different story. And reverse with sugammadex...best of both worlds.

 

[jwk]

The reality is that if cost were not an issue, we would use suggamadex like water and folks would be saying"what is neostigtme?"

We already do that. I'll bet it's been at least three years since I've used neostigmine.

 

[jwk]

It's restricted in ours. The nurse has to leave the room to get it from the Omnicell. They also have to type in the name of the anesthesiologist (why?) who's requesting the drug, and choose one of four options as to the reason why it's being pulled.

Sometimes it's out, so they have to then go to PACU and hope it's in theirs.

This is absolutely pointless. Maybe these new guidelines will be good ammunition for the idiot bean counters.

I wonder how many disposable surgical supplies are opened and never used in your OR just because they're on the surgeon's preference list? How many Davinci-only disposables are used in cases that could easily be done without the robot? How many ORs are opened and never used because of case cancellations?

 

[dabears505]

All the people saying that suggamadex has allergic reaction complications aren't mentioning the many complications from neostigmine/glyco. I've seen horrible bronchospasm, new onset a fib as well as reintubation due to inadequate reversal from neo/glyco. We need to put those drugs in the trash and move on.

 

[Chief's Pineapple]

This is absolutely pointless.

No argument from me. The nurses hate it because they have to leave the room, not to mention all the stuff they have to type in when they do get to the Omnicell... and if it's out on that not-so-rare occasion, the machine won't tell them until they get to the withdrawal part. Then they either have to go back to the room to call pharmacy to get it tubed up or go to another Omnicell and start the process over. Correct me if I'm wrong (I'm not an anesthesiologist), but I'm under the impression that if you need it during extubation, you need it pretty quick, no?

It's like, the doctors are going to use sugammadex anyways...just stick it in their carts to begin with.

I wonder how many disposable surgical supplies are opened and never used in your OR just because they're on the surgeon's preference list? How many Davinci-only disposables are used in cases that could easily be done without the robot? How many ORs are opened and never used because of case cancellations?

To answer these points, for the first one, there are usually extra towels, and sometimes gloves and even gowns, left over after the case is done. I try to take the towels and gloves home because they're just going to get trashed anyways, and they make good use for cleaning around the home. As for the second question, not sure. Your last question, happens once in a while. A little vial of sugammadex probably costs way less than all those supplies, but I can't be sure. The hospital wants to be cheap with no real financial gains with restricting sugammadex, I think.

 

[DocVapor]

No argument from me. The nurses hate it because they have to leave the room, not to mention all the stuff they have to type in when they do get to the Omnicell... and if it's out on that not-so-rare occasion, the machine won't tell them until they get to the withdrawal part. Then they either have to go back to the room to call pharmacy to get it tubed up or go to another Omnicell and start the process over. Correct me if I'm wrong (I'm not an anesthesiologist), but I'm under the impression that if you need it during extubation, you need it pretty quick, no?

It's like, the doctors are going to use sugammadex anyways...just stick it in their carts to begin with.

To answer these points, for the first one, there are usually extra towels, and sometimes gloves and even gowns, left over after the case is done. I try to take the towels and gloves home because they're just going to get trashed anyways, and they make good use for cleaning around the home. As for the second question, not sure. Your last question, happens once in a while. A little vial of sugammadex probably costs way less than all those supplies, but I can't be sure. The hospital wants to be cheap with no real financial gains with restricting sugammadex, I think.

For routine post-case reversal, sugammadex use is something that is planned and thus steps can be taken early enough to make sure it's ready when needed.

There are cases where it's needed unexpectedly and emergently (these should be exceedingly rare with a good anesthesiologist). I don't want to say that not having sugammadex available immediately in these situations guarantees patient harm or death... but it raises the risks of it tremendously. One lawsuit from something like this will more than wipe out years of savings by not stocking it in the cart.

 

[nimbus]

This is absolutely pointless. Maybe these new guidelines will be good ammunition for the idiot bean counters.

I wonder how many disposable surgical supplies are opened and never used in your OR just because they're on the surgeon's preference list? How many Davinci-only disposables are used in cases that could easily be done without the robot? How many ORs are opened and never used because of case cancellations?

Different silo. Pharmacy bean counters don’t care what happens if it’s not counted in the pharmacy column.

 

[Beeftenderloin]

All the people saying that suggamadex has allergic reaction complications aren't mentioning the many complications from neostigmine/glyco. I've seen horrible bronchospasm, new onset a fib as well as reintubation due to inadequate reversal from neo/glyco. We need to put those drugs in the trash and move on.

My old co-fellow in fellowship thought they were being clever and gave just neostigmine and no glyco to a patient that had a heart transplant several years prior because the heart was denervated so they couldn’t get bradycardia/asystole. The patient **** themselves on the table. Never got bradycardic though.

 

[lotsapain]

It's significantly faster and more predictable than neostigmine. Also allows for reversal of a deeper block.

I really see no advantage to using neostigmine over sugammadex other than maybe cost? And these days... depending on your pharmacy..it's not a significant difference

There are a number of cases of negative pressure pulmonary edema due to rapid reversal of deep blockade, more so then anaphylactic reactions.

 

[deleted875186]

There are a number of cases of negative pressure pulmonary edema due to rapid reversal of deep blockade, more so then anaphylactic reactions.

Please explain. So patient has an ETT, is reversed, and then what bites on the tube? Seems more related to poor technique rather than the drug.

 

[Dr. Rude]

I am not a lawyer, but... in my understanding, the ASA does not define the standard of care. Nobody specific does. We all do, together, by the way we practice.

The standard of care is what most reasonable doctors would have done in the same situation. So if most of us use sux or roc for RSI, that's the standard of care. If most of us would use EtCO2 for every moderate/deep sedation case, that's the standard of care. If most of us use U/S for blocks, that's the standard of care.

Not because the ASA, the ABA or God say it.

Agree, but it is established in court by expert OPINION testimony.

 

[Ashers]

One hospital I just worked, you had to give a reason WHY your gave sugammadex every time you used it. They are trying to discourage use. Maybe that'll go away.

 

[Arch Guillotti]

There are a number of cases of negative pressure pulmonary edema due to rapid reversal of deep blockade, more so then anaphylactic reactions.

Wait, what? Do you have a reference?

 

[UscGhost]

Wait, what? Do you have a reference?

Based on my Google search, they had a case of laryngospasm after extubation.

I don't see how sugammadex or neostigmine makes any difference in laryngospasm rates

 

[nimbus]

There are a number of cases of negative pressure pulmonary edema due to rapid reversal of deep blockade, more so then anaphylactic reactions.

I agree you’re less like to get NPPE with a patient who still has residual NMB at extubation. Hard to generate strong negative intrathoracic pressure when you’re flopping like a fish.

 

[vector2]

Based on my Google search, they had a case of laryngospasm after extubation.

I don't see how sugammadex or neostigmine makes any difference in laryngospasm rates

I think the reversal rapidity (fully relaxed to strong as an ox in a few seconds) combined with the fact that people can reverse at literally the last second as the pt is in various stages of emergence probably could explain some increased incidence of NPPE/spasm.

But that's still a fault of the user, not the drug.

 

[Greenbayslacker]

There are a number of cases of negative pressure pulmonary edema due to rapid reversal of deep blockade, more so then anaphylactic reactions.

Just use a soft bite block. Poor technique for emergence shouldn't be a reason to restrict sugammadex use/access

 

[epidural man]

One hospital I just worked, you had to give a reason WHY your gave sugammadex every time you used it. They are trying to discourage use. Maybe that'll go away.

It absolutely will go away after a single lawsuit….which is coming.

Most of us would GLADLY sit on the stand for the prosecution and say “yes, this lost airway and death could have been 100% avoided had the pharmacy not been stingy and placed the only drug that would help in the cart. It is the hospital’s greed that killed this patient. The anesthesiologist’s hands were tied by administrators. And might I add, MOST hospitals make it immediately available.” Yeah…keeping it outside the OR is a big payout waiting to happen.

In the last 20 years or more in this field, nothing has changed or really advanced, except for two things: suggamadex and video laryngoscopy. To ignore the first is risky.

 

[epidural man]

If a patient is having an anaphylaxis reaction to roc or vec, would suggamadex help?

 

[Dr. Rude]

It absolutely will go away after a single lawsuit….which is coming.

Most of us would GLADLY sit on the stand for the prosecution and say “yes, this lost airway and death could have been 100% avoided had the pharmacy not been stingy and placed the only drug that would help in the cart. It is the hospital’s greed that killed this patient. The anesthesiologist’s hands were tied by administrators. And might I add, MOST hospitals make it immediately available.” Yeah…keeping it outside the OR is a big payout waiting to happen.

In the last 20 years or more in this field, nothing has changed or really advanced, except for two things: suggamadex and video laryngoscopy. To ignore the first is risky.

Nope. You still are not supposed to remove the endotracheal tube until the patient meets criteria for extubation. Extubating a weak patient was bad care before suggamadex came out. That is how it will play out.

 

[Onefellswoop87]

If a patient is having an anaphylaxis reaction to roc or vec, would suggamadex help?

Presumably along the same lines that telling someone to stop eating shrimp who is having allergic reaction to it, but it’s not it would be first line treatment for allergic reaction/anaphylaxis. The IgE and histamine cascade has started already by then. I’d give the suggamadex but after epi and other supportive anaphylaxis treatment