Defasciculating dose before Succs?

The practice is dogma from days long ago. It is no longer required as it once was. Some people still probably insist on you doing it in school, and that is fine, but it just does not matter. Not even a little bit. Pretreat or not, same K+ shifts, same increase in IOP, same increase in abdominal pressure, same myalgias. It really just makes the patient look better at induction, but there is a literal ton of literature out there that says they will still have just as much myalgias. Like cricoid pressure, it is going to take several generations for this dogma to die.

And there's no need to give robinul before neostigmine, ie, you can very safely mix the two in the same syringe.

I agree the dogma is rampant wtbCRNA which I find frustrating as an SRNA spending my life chained to a desk learning a tidal wave of information to only find it's dogma or not clinically applicable. The only question I have about the topics you listed (which are contentious in the anesthesia community) is the risk for aspiration after X weeks in pregnancy. We were taught that the actual number of weeks is flexible but many choose to tube after 12-14 weeks due to the progesterone effects of relaxing the lower esophageal sphincter. Have you found this to not be true?

Offlabel, I do know people who give them mixed in the same syringe. I believe the onset is faster in the robinul which is why it can be justified to be given in the same syringe. Now if you tell me you don't give it at all and don't have muscarinic side effects you'll blow my mind.

I don't believe aspiration is increased risk....

And I don't believe in aspiration of CSF at the end of a spinal injection either!

Bluebolt,

i wish my anesthesiologist had given me roc with sux last week. I woke up at 3 the next morning with every muscle in my body inflamed as tho I had a terrible case of the flu. I had gone in for an arthroscopic that had been done before with Propofol and a strong local, but the new anesthesiologist required GA. It was at an outpatient clinic so I was in their recovery for a very short time before I was discharged and out the door. I was in extreme muscle pain for 2 days and actually had to use a cane to walk.

I'm still not sure why folks use succs for non (bonafide) RSI in the first place when they're just going to follow it up with with an NDM anyway.

We know in anesthesia e4very drug has its side effects and unfortunately, Sux is one of them. I try not to use it unless I have an obese patient with a questionable airway or if I am doing a case where neuromonitoring of motor evoked potentials is being used. We know that guys who are very muscular experience myalgia and should be avoided. I work in the Bronx NY area and at my trauma center job most of the docs routinely like to use Sux but at my per diem ambulatory surgery job, we like to use Roc since most of our cases tend to be ASA 1 and II type patients. Thank God for Suggamadex in our aresenal.

I'm still not sure why folks use succs for non (bonafide) RSI in the first place when they're just going to follow it up with with an NDM anyway.

I am someone who mostly uses Succs for all my cases, but I do avoid non depolarizes all together for most cases as well.

I agree and don't usually give a defasculating dose before my SCh, when I use it. Several points: (1) the defasc. dose needs to be on board for a few minutes, so I should give it when I get the pt on the table, (2) I use 5mg roc, if I use it at all -- still can see respiratory compromise prior to induction with this, and certainly if you let 10mg roc set up for a few minutes, (3) suggamadex is a game changer (but does have SEs at dose required to reverse a full RSI dose of roc), thus I use SCh much more rarely (usually in places that don't have Sugg), (4) I always, always mix my glyco with my neostig -- not because of onset, but because it removes the possibility of a major error (i.e., give the neostig. and forget/get distracted/whatever and not give the glyco in a timely fashion = bradycardia, SLUDE, profound problems), which I prefer to avoid.

Sorry about the run-on sentence. Just my $0.02.

God bless