Residual NMBA in cellsaver

Tenesma · Nov 1, 2003

why is a sux drip unethical???

in an environment where your surgeons are extremely fast and you have a high caseload, thus requiring a rapid turnover rate - how else would you provide the muscle relaxation necessary for a laparoscopic chole?.... i give on the low end of sux for rapid sequence intubation (most hot gallbladders should be considered full stomachs) and then I mix up 100mg of succinylcholine in a 100cc bag, i hook up a twitch monitor... I open the bag wide open when the surgeon needs true relaxation and i turn it off when he doesn't... the patient wakes up quick with no muscle weakness... seldom do i ever end up giving more than 130-150mg of succinylcholine (and that includes the intubation dose)for an average 80kg patient (gallbladders are usually hot in fatter patients)... now if I really want to save my succinylcholine for the drip, instead of wasting it on the rapid sequence intubation - i substitute remifentanyl at 4-5mcg/kg bolus for intubation - it has been shown to provide close to the same amount of airway areflexia... of course there are other alternatives, but the great thing about anesthesia is the variety :)

edrophonium (about 30-40$ per vial) given 0.5mg/kg when patient has 3 or 4 twitches - VERY rapid onset of strength and quick decay... i usually mix atropine with the edrophonium instead of glycopyrrolate because its curve matches edrophonium better, and i use about 10mcg/kg of atropine... so for a 70kg pt that would be about 35mg of edrophonium w/ 0.7mg of atropine... i am very lucky at my hospital - in as much as quite a few of my attendings have pretty much developed the field of neuro-muscular blockade (ie: atracurium, cisatracurium etc were invented here), and the good news is that they are close to finishing early clinical trials on a new benzylisoquinolone that has the pharmacokinetic properties of succinylcholine!!! keep your fingers crossed, because anesthesia may become even safer and easier :)

zambezi, BSN, RN · Nov 1, 2003

back to the start of the thread mentioning cell saver...we use cell saver in our open heart unit if we have greater than 600cc/hr out in a post op patient. It is on our standing orders, but only one or two of our docs checks it. The rest of our patients we can autotransfuse if >200cc/hr out.... (for up to six hours pos op). If the doc wants us to cellsave, we call the cellsaver tech who comes to spin the blood down and we hang it like a normal unit of blood.

loisane · Nov 1, 2003

I agree with Tensma 110% about sux gtts. They no longer make the plastic vial powder-pack we used to use to make sux gtts at a half a liter at a time. Probably just as well, for infection control purposes. But just because that product is no longer available, doesn't mean the use of sux as an infusion is no longer acceptable.

You just have to be more creative, which is part of the fun of anesthesia, anyway. A 100 cc minibag works great. If you buy them empty of fluid, it is cheaper. If you do alot of these cases, you can mix a 500 cc bag of sux gtt, and then divide it into the minibags, to cut your costs down.

Rocuronium is perfect for most of the lap choles I do now. But it depends on your surgeon. On my first day with this one fellow-I did the first case with rocuronium, the second with nimbex, and by the third I realized a sux gtt was the only thing that was going to enable me to keep up with the guy!

More recently I have used sux for outpt gyn lap exams and tubals. Tried mivacron, wasn't too bad, but sux matched better. These cases were so quick, I ended up just diluting 60 mg in a 60 cc syringe, and pushing it just a little bit at a time. With a minibag, but the time I had it running, and titrated to the right twitch, the case was over, so the syringe ended up being easier.

I like edrophonium too. One trick I was taught as a student was, if the patient was just barely reversible, to add a little to your neostigmine reversal. With 10mg of edrophonium added, the patient would be much stronger. I always worried that the edrophonium's effects would wear off more quickly, leaving the patient with residual weakness in PACU. So I was always relieved when the PACU nurse was a sharp RN, who fully understood what I had done, and knew what to watch closely for. I never got burned, so either this is a good trick, or I was just lucky!

loisane crna

edited to correct my mistake of referring to "romazicon", when I meant "rocuronium". Thanks to deepz for pointing it out. loisane

stevierae · Nov 1, 2003

Originally posted by Tenesma
why is a sux drip unethical???

Yeah, no kidding, why is a sux drip unethical? What's wrong with using something cheap and effective for these short cases?

I have never seen sux drips go out of vogue; silly to waste money on a more expensive drug when the old tried and true works just as well.

It's just like antibiotics--no reason to use one of the more expensive 6th or 7th generation cephalosporins when Ancef does the same thing for pennies.

TraumaNurse · Nov 2, 2003

I just wanted to say that I love these clinical discussions! Keep it up! I can't wait until I can actually jump in too. Thanks.

Athlein · Nov 2, 2003

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deepz · Nov 2, 2003

Well, PMMAIS (Pardon Me, My Age Is Showing)

Without a doubt, I'd nominate the sux drip as THE most widely abused anesthetic technic of all time. But then I go back a ways: forty years. I confess I'm surprised to hear the sux drip is regaining any degree of legitimacy, even for special applications and academic exercises. Wow!

From the mid-1960s, for the lazier ones among my colleagues, the sux drip was the universal relaxant; many oldtimers still clung to it exclusively after pancuronium arrived, on into the 80s. So easy -- make up a bag with one or two 1 Gm Anectine Flo-Packs in it ... use it all day long ... and all night. (If ... if you remembered to cut back the full blast drip rate after intubation. [No controlled infusors then; occasionally a patient received the whole bag, a gram or two of sux at induction.]) And then maybe refrigerate the bag and use it the next day too. The absolute height of laziness. At the end of each case just clamp the tubing with a rubber-shod hemostat and change ONLY the NEEDLE between patients.

Eight minute cases or eight hours ... sux drip. Of course there were many phase II blocks, etc. I saw complications up to and including hypoxic brain damage and death, the cause commonly dismissed as arising from pseudocholine-esterase deficiency. Pure obfuscation.

Like I say: lots of history of abuse with the sux drip technic ... and lack of ethics. The two often seemed to go hand in hand. Sure sux is cheap. So is halothane. Both are also MH triggers. No thanks.

So then, thus my disinclination against one Lazy Man technic. In the early years of my career I gave thousands of sux drips; now I employ sux solely for RSI. Zemuron is perfectly adequate for 20 minute lap choles. At times I do add Enlon to my reversal, if needed, to speed matters up: an economical tradeoff against a longer $$$ stay in the OR.

deepz

Tenesma · Nov 2, 2003

deepz... i wonder how using a drug effectively and safely is a lazy man's technique... one of the surgeons here can literally pull a gallbladder out 10 minutes after betadine is on the patient...

the thing with sux is that for the most part when it is used it is dosed as a HUGE overdose... the recommended dose of 0.6 to 1mg/kg in adults is a true overdose if you look at what is actually needed to turn the muscles off... so in effect my quickie cases usually end up getting less sux for the whole case than most people use for their RSI!!!! about MH triggers... do you also choose not to use iso/sevo or des because of that?

sure it is an old technique gaining popularity, and when used carefully and smartly there are no problems...

muscle aches are attributed to sux, and other NMBAs (put to a lesser degree) - they are also attributed to positioning on the table and length of the procedure... so far, i have not had anybody ever complain of myalgias with my sux drips (i post-op them all that evening or the next day, and then again a week later with a follow-up call)... doesn't mean it won't happen

stevierae · Nov 3, 2003

Originally posted by deepz
Well, PMMAIS (Pardon Me, My Age Is Showing)

[No controlled infusors then; occasionally a patient received the whole bag, a gram or two of sux at induction.]) And then maybe refrigerate the bag and use it the next day too. So then, thus my disinclination against one Lazy Man technic. deepz

OF COURSE, there were controlled infusors then--don't you remember the old dial-a-flows; actually, they are still around--we (the OR nurses) always set them up on sux, Nipride, Dopamine, Neosynephrine, etc. drips--even to date , the only infusion pumps I see used in the OR are the ones used specifically for Diprivan--

I still see anesthesia providers come into each other other's rooms and say, "Can I borrow your sux drip?" Nothing wrong with that, in my opinion; they are just being economical--I don't think any of them are people I would in any way consider lazy--I remember people refrigerating drips (or even leaving them on their carts) to reuse the next day--heck, if the product is not expired or contaminated, why not? Didn't people always do that with 60 cc syringes of Pentothal? Gosh, I admire people who try to cut down on waste---operating rooms waste far too much as it is; things that could be easily recycled without compromising patient care---

stevierae · Nov 3, 2003

Originally posted by Athlein
Here's another perspective on succinylcholine drips - from the patient's point of view. In this case, the patient happened to be me:

Outpatient procedure - "super-quick" according to surgeon. Lasted longer than expected, though. I woke up feeling like I had been hit by a train. My muscles ached so badly. It was terrible.

I was told that it was due to my body habitus (endurance athlete - low body fat, muscular) and that it would go away in a few hours. The aches subsided, but it took a couple of days, and they were far worse than the pain from my procedure.

Just something to think about....

Are you sure it was from the sux? I am wondering if the procedure you had was a laparoscopic one--i.e., lap chole or lap hernia--or, if you are a woman, a lap tubal--in which case some insufflated gas could have accumulated in your muscles (most often in your shoulders) and caused what you are describing--

I know after I have had laparospic surgery I experienced the same phenomenon, and I know sux wasn't used---I had no post-op pain other than what you are describing, and it truly was agonizing, and did take several days to subside--similar to what I've experienced after a strenuous workout done after getting out of shape, when lactic acid accumulates in the joints due to anaerobic metabolism--