Teaching points: Defasciculating Doses

[sigrhoillusion]

This is very not good.

Yeah... not understanding this. I rarely use sux, only for true emergent full stomach RSI and for very short procedures <30 min on very fat people that I don't trust LMAs with or their head is away from the machine. But not sure why you would avoid sux in an RSI for a SLLLOOOOOWWWW sedation induction with high-dose rocuronium. What's the benefit to this? Why would you slowly titrate narcs/benzos and allow a patient to hypoventilate and lose airway control when you should be pre-oxygenating, then pushing prop/sux and then intubating after fasciculations without ventilating...?

I don't care what people say, but fent/versed is unpredictable in many patients. I've seen young healthy athletes get 2 of versed and by the time I'm back in the room they've gone from "bro don't taze me" to getting shook to arouse them to get them on the OR table and breathe cause you put a pulse ox on them and they are satting 92%. Then you get those people who you give 100 of vent and 2+ versed and they're still blabbing away.

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[sigrhoillusion]

Yeah... not understanding this. I rarely use sux, only for true emergent full stomach RSI and for very short procedures <30 min on very fat people that I don't trust LMAs with or their head is away from the machine. But not sure why you would avoid sux in an RSI for a SLLLOOOOOWWWW sedation induction with high-dose rocuronium. What's the benefit to this? Why would you slowly titrate narcs/benzos and allow a patient to hypoventilate and lose airway control when you should be pre-oxygenating, then pushing prop/sux and then intubating after fasciculations without ventilating...?

I don't care what people say, but fent/versed is unpredictable in many patients. I've seen young healthy athletes get 2 of versed and by the time I'm back in the room they've gone from "bro don't taze me" to getting shook to arouse them to get them on the OR table and breathe cause you put a pulse ox on them and they are satting 92%. Then you get those people who you give 100 of vent and 2+ versed and they're still blabbing away.

Also, I find that people who come up from the ER for surgery tend to be "decompensated" in the sense that they've been sitting in the ER for HOURS (sometimes a day). They are tired, they are hungry, they've been mismanaged, underhydrated and forgotten especially once the ER knows they are going up for surgery. MAybe this is "dogma" but they don't seem to require as much as your typical outpatient, or even inpatients who have been in a private room, watching TV and allowed to have dinner the night before.

 

[epidural man]

Sorry to dig up an old thread, but I need advice:

As a retired anesthesiologist, I (1) have given every patient to whom I've given sux pretreatment with 3 mg of curare, and (2) never had a complaint of post-op fasciculation pain.

Last year I had lumbar spine surgery, and the day after surgery I experienced pain in every muscle in my body...particularly when I needed to cough. It was awful. The pain pattern exactly matched all I've read about succinylcholine post-op fasciculation pain. I contacted my anesthesiologist, and indeed she gave me succinylcholine without a nondepolarizer pretreatment.

I'm thus convinced that such pretreatment is necessary. Since d-tubocurarine was considered an ancient drug in my time, and now seems to be unavailable, what is the modern alternative? in this thread I've see other depolarizers, and lidocaine. I expect to be having another GETA surgery: What should I ask for, in terms of moderns pharmaceuticals: name and dosage?

I don't want to go through that unnecessary post-sux pain again.

Just restating what others said -

Just politely ask that they don't use Sux. There are lots of other options. BUT, if they insist on sux, tell them to use an NSAID which has been shown to help decrease the pain. Also, larger doses of sux helps prevent the myalgias so ask for 2mg/kg. Finally, I don't think a defasiculating dose has shown to be that much helpful - but I may be remembering wrong.

 

[facted]

Just restating what others said -

Just politely ask that they don't use Sux. There are lots of other options. BUT, if they insist on sux, tell them to use an NSAID which has been shown to help decrease the pain. Also, larger doses of sux helps prevent the myalgias so ask for 2mg/kg. Finally, I don't think a defasiculating dose has shown to be that much helpful - but I may be remembering wrong.

What's the rationale for larger dose of sux being more effective to prevent myalgia? Doesn't make much intuitive sense.

 

[fakin' the funk]

What's the rationale for larger dose of sux being more effective to prevent myalgia? Doesn't make much intuitive sense.

And yet, it's true.

 

[fakin' the funk]

Just restating what others said -

Just politely ask that they don't use Sux. There are lots of other options. BUT, if they insist on sux, tell them to use an NSAID which has been shown to help decrease the pain. Also, larger doses of sux helps prevent the myalgias so ask for 2mg/kg. Finally, I don't think a defasiculating dose has shown to be that much helpful - but I may be remembering wrong.

This is the only article you need to read. We shall conjecture no longer.
Prevention of Succinylcholine-induced Fasciculation and Myalgia:A Meta-analysis of Randomized Trials | Anesthesiology | ASA Publications

 

[facted]

This is the only article you need to read. We shall conjecture no longer.
Prevention of Succinylcholine-induced Fasciculation and Myalgia:A Meta-analysis of Randomized Trials | Anesthesiology | ASA Publications

This study clearly shows that a defasiculating dose IS effective, with a NNT of as little as 3 for Roc, for example.

 

[dhb]

This study clearly shows that a defasiculating dose IS effective, with a NNT of as little as 3 for Roc, for example.

I like my NNT to be 1.
1 out of 3 sounds like placebo

 

[facted]

I like my NNT to be 1.
1 out of 3 sounds like placebo

Then it sounds like you skipped out on statistics courses.

In this study, NNT for zofran to prevent PONV was between 5-6. Do you believe zofran to be an effective anti-emetic?
Efficacy, dose-response, and safety of ondansetron in prevention of postoperative nausea and vomiting: a quantitative systematic review of randomiz... - PubMed - NCBI

 

[dhb]

Then it sounds like you skipped out on statistics courses.

Can't say i miss it.

 

[coffeebythelake]

I like my NNT to be 1.
1 out of 3 sounds like placebo

You would be very disappointed with the NNT of statins for heart attack, ASA plavix for cardiac stents, etc

 

[dhb]

You would be very disappointed with the NNT of statins for heart attack, ASA plavix for cardiac stents, etc

No i wouldn't. That's why i like propofol, muscle relaxant and local anesthetics.

 

[fakin' the funk]

No i wouldn't. That's why i like propofol, muscle relaxant and local anesthetics.

Your whole angle on NNT makes no sense.

 

[Psai]

You would be very disappointed with the NNT of statins for heart attack, ASA plavix for cardiac stents, etc

70℅ of the time, it works every time

 

[dhb]

Your whole angle on NNT makes no sense.

Enlighten us master Fakin