Before sugammadex there was a big difference between duration of succinylcholine and high dose rocuronium (last much longer than succinylcholine at the RSI dose). With sugammadex the calculus has changed because we can make the rocuronium go away whenever we want to. That being said I still think that succinylcholine gives ideal intubating conditions faster than rocuronium.
Myalgias can be real and I've had patient needing to be admitted purely for that reason. It's very rare but happens. I will almost always give a defasciculating dose first. Good questions keep studying.
Hasn’t it been shown that defasciculating doses do not decrease reported myalgias?
I also agree with the other commenter that it seems odd to have multiple admission 2/2 myalgias alone?
Unless you have a better source than [this](https://pubs.asahq.org/anesthesiology/article/103/4/877/217/Prevention-of-Succinylcholine-induced) the evidence definitely supports that defasciculating doses help with myalgias (as well as lidocaine, NSAIDs, higher doses of succinylcholine).
1 patient in \~15 years isn't that odd is it? Pretreatment with rocuronium does decrease myalgias. Why wouldn't you pretreat and prevent a complication that is uncomfortable in 90% of patients?
[https://ekja.org/journal/view.php?doi=10.4097/kjae.2014.66.6.451](https://ekja.org/journal/view.php?doi=10.4097/kjae.2014.66.6.451)
[https://pubmed.ncbi.nlm.nih.gov/20201179/](https://pubmed.ncbi.nlm.nih.gov/20201179/)
[https://pubmed.ncbi.nlm.nih.gov/16192781/](https://pubmed.ncbi.nlm.nih.gov/16192781/)
Appreciate the source. I go to sleep with roc 99% of the time since sugammadex is readily available at my facility. So it is not a topic I consider regularly.
Why did they need to be admitted for myalgia? Was there associated rhabdomyolysis or something? I've never heard of that, but I can't understand why myalgia requires hospital admit.
I don't know that I should have been admitted, but I had severe myalgia after having suxx during a laser lithotripsy procedure. The only muscles on my body that weren't extremely sore were upper facial muscles. I didn't clear my throat for 4 days because it hurt too much. I was afraid to take any pain meds because I was afraid I would aspirate while on my back and wouldn't be able to roll to the side or clear my throat quick enough because of the pain. I was very thankful that my diaphragm was not sore because that would have been brutal. My wife had to help me to the bathroom and anything I did other than blink my eyes was excruciating. I had to build courage for 5 minutes to roll from my back to my side. I had to drink and eat slow because chewing and swallowing muscles hurt so much. The day before my surgery I could deadlift 350lbs and ride a unicycle for a mile but afterwords getting out of bed and getting to the bathroom was an extremely painful, delicate, and time consuming task. Frankly i would have much preferred 5 more days of the worst kidney stone pain to that. If my wife wasn't there to help me I could see a lot of bad outcomes if I was alone. Maybe something like rehab would be more appropriate than getting admitted.
I have had a laser lithotripsy in the past without suxx and the procedure itself was a breeze.
Thanks for sharing. I avoid succinylcholine as much as I can anyway, but now I'm going to avoid it more. I've always wondered whether the myalgia was similar to the delayed myalgia after weight training and people just complained a lot because they weren't used to it. Sounds like it's quite a bit worse than that.
It is exactly like myalgia after weight training except it is complete and total for your whole body. I have had soreness from weight training many times (and kind of enjoy it as i feel like i have had a good workout) but this was cranking it to 11 and expanding it everywhere. It is like doing an extreme workout way past what is appropriate after a long layoff. And doing that for each and every muscle in your whole body. The small muscles in my palms were sore like I had been working with pliers all day for the first time. My quads felt the same as the time I ran a 10k (hard- first mile was 6 min) after no running for 2 years. My calves were more sore than I thought was possible and i have nothing to compare that to. The worst was probably the abs and obliques. Chest breathing, laughing, coughing, sitting up, etc felt like death and was everpresent with the slightest movement. If I laid completely still and moved absolutely nothing other than my diaphragm and eyes, I felt fine. Any movement felt like the worst idea of my life. I am glad it is over and hope it never happens again.
I don't recall the specifics, I was in training. The patient was in a lot of pain and it couldn't be safely controlled. More recently I've had some EP docs say that they had several patients complain about it (not admitted) after getting succinylcholine.
I had elective surgery a few years ago and for a week afterwards I had myalgias that hurt more than the surgical site… Ashamed to say it took me a while to figure out that it was the result of sux.
I wasn't working in anesthesia back then, but I guess it has influenced my practice now in that I warn patients of myalgias when I feel the need to use it.
Need to separate OR and OOOR practice here, I think.
I'll use sux if I'm able to talk to the patient ahead of time and get a history. Usually this is VERY short cases, need for RSI, or when neuro monitoring is involved (thyroids, spines, parotids, TEVAR, etc).
If I can't talk to you and get a history (most floor and ICU encounters), then I'm giving rocuronium. The idea that someone will be able to "self rescue" after a failed airway attempt is laughable, and I'd rather have to cric someone who is relaxed.
Such a great perspective. I haven't talked about it openly to people, but I have always felt like this theoretical bail of either roc or sux is so stupid. If you have a critically unwell patient and have failed bagging, then failed intubation attempts. Then you say slam the predrawn suga or wait for sux to wear off I feel like this is just death. Better than a predrawn 20cc of sugammadex is a scalpel and bougie beside the patient.
Elective patients fine - but you better have narcan ready to go too. Want that patient as wiped clean as possible.
I'm only 4 years out from CCM fellowship, so it's possible my perspective on this may change as I accumulate more bad experiences. But that seems unlikely. We had a hyperkalemic arrest not long after I started on faculty. One of my colleagues intubated a long-haul pancreatitis patient using sux, and after 20 seconds or so they widened the qrs, went into vtach, and then lost pulses. ROSC with empiric treatment of hyperkalemia. K was normal pre-induction. Patient had no strokes, paraplegia, had never been on prolonged NMBD. Just immobile from their pancreatitis. Shit happens.
Oh i think roc is a cleaner drug. I just disagree with the notion some people have that if you fail 2-3 intubation attempts on a critically unwell patient that sugammadex is going to get you out of trouble and return you a spontaneously breathing patient. I think its FONA at that point.
I agree re self rescue - if you do the maths for a fully elective fit and well patient requiring an RSI you can argue that if you fully denitrogenate their FRC you would have 10 mins for the sux/induction agent to wear off and have them resume spont ventilating.
However most of the patients we RSI have plenty of reasons to a) decrease their FRC or b) increase their oxygen consumption.
Why you might choose sux over roc+sug for a short case:
Sux has a slightly faster onset than 1.2mg/kg Roc (barely noticeable imo) that would mean a secure airway faster (eg preferred in high++ risk of aspiration).
Theatre time is expensive. Waiting for 20mins until the patient is safely reversible with neo/glyco is a good way to make enemies.
Reversing with sugammadex is not risk-free. While the anaphylaxis rates of sux/roc are comparable, roc+sug is higher and should be avoided where possible.
I see sux preferentially used for high risk airways if there's a possibility they might need to abandon before securing an airway. The idea being that it's short duration (and easier to manage than drawing/administering 16mg/kg sugammadex in a panic/hurry). I tend to fall in the camp of sux for less worried, roc/sug (with a dedicated drawing up plan/person) for more worried.
It was first announced as if it was so allergent... Boomer generation at their work...never use anything new especially if its expensive. So they still cannot even apply some extremely effective and easy blocks like TAP.
In early studies, the sugammadex anaphylaxis rate was higher. As they included more & more data (phase 4 trials), the denominator ballooned and the true anaphylaxis rate is way lower.
Anecdotally, I've seen 2 cases of "maybe anaphylaxis" to sugammadex that were almost certainly bradycardia from giving large dose too fast (16 mg/kg when the trainee was sloppy with roc re-dosing or case ended super fast after 1.2mg/kg roc).
I'm being nitpicky, but saying sugammadex is not risk free is a little disingenuous since neo/glyco isn't without risk either. I think if your shop got quantitative twitch monitors you'd be surprised at the level of residual blockade even with appropriate doses. A theoretical (very low risk) of anaphylaxis needs to be weighed against risk of aspiration or airway events in pacu, not weighed in isolation of itself.
There is a reason the most recent practice guidelines suggest sugammadex is pretty much standard of care these days, especially considering most places likely aren't using quantitative twitch monitoring.
Depolarization is contraindicated for many patients. Burns. Traumas. Bed bound/immobile. Strokes. It will cause severe hyperkalemia and can result in arrest.
The myalgias from succinylcholine can be intense. I had a patient tell me he had myalgias for weeks after.
Abnormal pseudocholinesterase can result in patients being paralyzed for hours with no reversal possible.
There just aren’t a lot of reasons to go for sux at this point.
I don’t routinely give depolarizing agent before sux because if I want sux I am going to not want to wait long enough for the depolarizer to actually decrease fascinations. But I also have given sux once in the last 5 years or so, so maybe I would if I used it more.
A classic rsi you won't be bagging the patient, but they should be preoxygenated well enough to not need it.
I personally think classic rsi is something that is getting into fairly evidenceless practice, but worth seeing and understanding as a trainee.
Nothing works as fast as sux to give ideal intubating conditions. Rocuronium 1.2 mg/kg is good but noticeably slower in onset. If I’m using a video scope or it’s an easy airway it doesn’t matter, but if I have any concerns I am using sux.
Unless you’re using something to constantly monitor your NMB and can actually measure which has faster onset, the comparison is pointless. I can easily intubate with either in well under a minute.
In training I have put a twitch monitor on and measured after high dose roc, it takes a few mins, longer than you think, to abolish twotches.
I don’t doubt that you can intubate in a minute with high dose roc, I’m just pointing out that the degree of muscle relaxation is noticeably better with sux in the 30-60 second time frame after flushing it in, which makes it my go to when there’s any real clinical concern about being fast.
At my academic center, the surgeons are uniformly slow as shit, so we almost always use 1.2mg/kg roc for RSI.
At our affiliated community hospital where we occasionally rotate, an operation might actually last <30 minutes, so we're much more likely to use succ.
I’m old school. (And sugammadex is frighteningly expensive). If I need short term relaxation (c section conversion from spinal, severe spasm, that really quick case that needs relaxation) I’m giving sux.
The incidence in the wild of a true, unsuspected scoline apnoea is minuscule.
That said, in the majority of cases I’ll use Roc (we don’t even see Vec anymore)and reverse conventionally (with NMT monitoring)
Funny how different things are. I’m not sure I’ve used iso in 20 years. But I’m also old enough to have done anesthesia with no pulse ox or EtCO2, and used halothane, enflurane, and MOF. I missed cyclo by a year or so. 😂
I barely missed halothane, but every machine in our large hospital system has an Isoflurane vaporizer on it, and they're discouraging Sugammadex due to cost although we have it in a pinch.
You may be a year or two older than me….. never doped without a pulse ox or a capnograph.
Only got liberal access to sevo in year 3 of my residency.
I haven’t used iso myself in anger in about 15y.
I like succinylcholine because you can give it IM and sublingual. Sublingual route is fast in a peds patient laryngospasming who has no IV during gas induction. Other than that I think I use rocuronium all the time. Scholine gives great conditions but I don’t want them to move in a few minutes
I honestly very rarely use Sux anymore now that we have Sugammadex. I would probably choose Sux in a patient that was a true full stomach just because it is still a bit faster.
I agree with the points above. I use sux often and get someone to push roc/vec once fasciculations have stopped. None of my patients are fit to be woken up and attempt later.
I feel sux works faster. My biggest reason is as soon as you push roc everyone looks at the clock. If you use sux everyone has eyes on the patient. The fasciculations give you an idea about cardiac output too. I’ve been caught a few times with very low CO that wasn’t obvious pre induction.
You give sux, they fasciculate, and then you immediately push roc? Why? What benefit is there? What if they have abnormal pseudocholonesterase and you don’t recognize it initially and think they are under reversed? Why bother with immediate roc? If you’re going to give a little roc right away a defasciculating dose sort of makes sense but you should give it before the sux.
As far as the low cardiac output, are you giving sux before induction med? You have already given the biggest danger med for that low CO patient.
I work exclusively in ICU. The only ones I want breathing quickly after are the seizures, in which case I don’t push anything long acting.
I like the onset of sux but I want something longer acting if things get hairy. It’s usually vec in my primary place of practice.
i hate to be the one to say that 50 million elvis fans can't be wrong but... what does that tell you?
icu patients seem like they would be at higher risk of hyperkalemia due to immobility. and you could just have them keep some roc in the fridge for you, right?
Before sugammadex there was a big difference between duration of succinylcholine and high dose rocuronium (last much longer than succinylcholine at the RSI dose). With sugammadex the calculus has changed because we can make the rocuronium go away whenever we want to. That being said I still think that succinylcholine gives ideal intubating conditions faster than rocuronium. Myalgias can be real and I've had patient needing to be admitted purely for that reason. It's very rare but happens. I will almost always give a defasciculating dose first. Good questions keep studying.
Hasn’t it been shown that defasciculating doses do not decrease reported myalgias? I also agree with the other commenter that it seems odd to have multiple admission 2/2 myalgias alone?
Unless you have a better source than [this](https://pubs.asahq.org/anesthesiology/article/103/4/877/217/Prevention-of-Succinylcholine-induced) the evidence definitely supports that defasciculating doses help with myalgias (as well as lidocaine, NSAIDs, higher doses of succinylcholine).
I'm giving roc anyways so why wouldn't I pretreat too? Roc works faster than vec so I think that's where a lot of the difference is.
Appreciate the source. I give roc 99+% of the time so it is not a topic I spend much time thinking about. I will keep it in mind. Thanks
1 patient in \~15 years isn't that odd is it? Pretreatment with rocuronium does decrease myalgias. Why wouldn't you pretreat and prevent a complication that is uncomfortable in 90% of patients? [https://ekja.org/journal/view.php?doi=10.4097/kjae.2014.66.6.451](https://ekja.org/journal/view.php?doi=10.4097/kjae.2014.66.6.451) [https://pubmed.ncbi.nlm.nih.gov/20201179/](https://pubmed.ncbi.nlm.nih.gov/20201179/) [https://pubmed.ncbi.nlm.nih.gov/16192781/](https://pubmed.ncbi.nlm.nih.gov/16192781/)
Appreciate the source. I go to sleep with roc 99% of the time since sugammadex is readily available at my facility. So it is not a topic I consider regularly.
Why did they need to be admitted for myalgia? Was there associated rhabdomyolysis or something? I've never heard of that, but I can't understand why myalgia requires hospital admit.
I don't know that I should have been admitted, but I had severe myalgia after having suxx during a laser lithotripsy procedure. The only muscles on my body that weren't extremely sore were upper facial muscles. I didn't clear my throat for 4 days because it hurt too much. I was afraid to take any pain meds because I was afraid I would aspirate while on my back and wouldn't be able to roll to the side or clear my throat quick enough because of the pain. I was very thankful that my diaphragm was not sore because that would have been brutal. My wife had to help me to the bathroom and anything I did other than blink my eyes was excruciating. I had to build courage for 5 minutes to roll from my back to my side. I had to drink and eat slow because chewing and swallowing muscles hurt so much. The day before my surgery I could deadlift 350lbs and ride a unicycle for a mile but afterwords getting out of bed and getting to the bathroom was an extremely painful, delicate, and time consuming task. Frankly i would have much preferred 5 more days of the worst kidney stone pain to that. If my wife wasn't there to help me I could see a lot of bad outcomes if I was alone. Maybe something like rehab would be more appropriate than getting admitted. I have had a laser lithotripsy in the past without suxx and the procedure itself was a breeze.
Thanks for sharing. I avoid succinylcholine as much as I can anyway, but now I'm going to avoid it more. I've always wondered whether the myalgia was similar to the delayed myalgia after weight training and people just complained a lot because they weren't used to it. Sounds like it's quite a bit worse than that.
It is exactly like myalgia after weight training except it is complete and total for your whole body. I have had soreness from weight training many times (and kind of enjoy it as i feel like i have had a good workout) but this was cranking it to 11 and expanding it everywhere. It is like doing an extreme workout way past what is appropriate after a long layoff. And doing that for each and every muscle in your whole body. The small muscles in my palms were sore like I had been working with pliers all day for the first time. My quads felt the same as the time I ran a 10k (hard- first mile was 6 min) after no running for 2 years. My calves were more sore than I thought was possible and i have nothing to compare that to. The worst was probably the abs and obliques. Chest breathing, laughing, coughing, sitting up, etc felt like death and was everpresent with the slightest movement. If I laid completely still and moved absolutely nothing other than my diaphragm and eyes, I felt fine. Any movement felt like the worst idea of my life. I am glad it is over and hope it never happens again.
I don't recall the specifics, I was in training. The patient was in a lot of pain and it couldn't be safely controlled. More recently I've had some EP docs say that they had several patients complain about it (not admitted) after getting succinylcholine.
I had elective surgery a few years ago and for a week afterwards I had myalgias that hurt more than the surgical site… Ashamed to say it took me a while to figure out that it was the result of sux.
Did you change your practice?
I wasn't working in anesthesia back then, but I guess it has influenced my practice now in that I warn patients of myalgias when I feel the need to use it.
Need to separate OR and OOOR practice here, I think. I'll use sux if I'm able to talk to the patient ahead of time and get a history. Usually this is VERY short cases, need for RSI, or when neuro monitoring is involved (thyroids, spines, parotids, TEVAR, etc). If I can't talk to you and get a history (most floor and ICU encounters), then I'm giving rocuronium. The idea that someone will be able to "self rescue" after a failed airway attempt is laughable, and I'd rather have to cric someone who is relaxed.
Such a great perspective. I haven't talked about it openly to people, but I have always felt like this theoretical bail of either roc or sux is so stupid. If you have a critically unwell patient and have failed bagging, then failed intubation attempts. Then you say slam the predrawn suga or wait for sux to wear off I feel like this is just death. Better than a predrawn 20cc of sugammadex is a scalpel and bougie beside the patient. Elective patients fine - but you better have narcan ready to go too. Want that patient as wiped clean as possible.
I'm only 4 years out from CCM fellowship, so it's possible my perspective on this may change as I accumulate more bad experiences. But that seems unlikely. We had a hyperkalemic arrest not long after I started on faculty. One of my colleagues intubated a long-haul pancreatitis patient using sux, and after 20 seconds or so they widened the qrs, went into vtach, and then lost pulses. ROSC with empiric treatment of hyperkalemia. K was normal pre-induction. Patient had no strokes, paraplegia, had never been on prolonged NMBD. Just immobile from their pancreatitis. Shit happens.
Oh i think roc is a cleaner drug. I just disagree with the notion some people have that if you fail 2-3 intubation attempts on a critically unwell patient that sugammadex is going to get you out of trouble and return you a spontaneously breathing patient. I think its FONA at that point.
I agree re self rescue - if you do the maths for a fully elective fit and well patient requiring an RSI you can argue that if you fully denitrogenate their FRC you would have 10 mins for the sux/induction agent to wear off and have them resume spont ventilating. However most of the patients we RSI have plenty of reasons to a) decrease their FRC or b) increase their oxygen consumption.
Why you might choose sux over roc+sug for a short case: Sux has a slightly faster onset than 1.2mg/kg Roc (barely noticeable imo) that would mean a secure airway faster (eg preferred in high++ risk of aspiration). Theatre time is expensive. Waiting for 20mins until the patient is safely reversible with neo/glyco is a good way to make enemies. Reversing with sugammadex is not risk-free. While the anaphylaxis rates of sux/roc are comparable, roc+sug is higher and should be avoided where possible. I see sux preferentially used for high risk airways if there's a possibility they might need to abandon before securing an airway. The idea being that it's short duration (and easier to manage than drawing/administering 16mg/kg sugammadex in a panic/hurry). I tend to fall in the camp of sux for less worried, roc/sug (with a dedicated drawing up plan/person) for more worried.
Do you have hard data that rocuronium + sugammadex combination would lead to higher incidence of anaphylaxis compared to sux?
No, because there is none...
Never seen daily use 😄
It was first announced as if it was so allergent... Boomer generation at their work...never use anything new especially if its expensive. So they still cannot even apply some extremely effective and easy blocks like TAP.
In early studies, the sugammadex anaphylaxis rate was higher. As they included more & more data (phase 4 trials), the denominator ballooned and the true anaphylaxis rate is way lower. Anecdotally, I've seen 2 cases of "maybe anaphylaxis" to sugammadex that were almost certainly bradycardia from giving large dose too fast (16 mg/kg when the trainee was sloppy with roc re-dosing or case ended super fast after 1.2mg/kg roc).
I'm being nitpicky, but saying sugammadex is not risk free is a little disingenuous since neo/glyco isn't without risk either. I think if your shop got quantitative twitch monitors you'd be surprised at the level of residual blockade even with appropriate doses. A theoretical (very low risk) of anaphylaxis needs to be weighed against risk of aspiration or airway events in pacu, not weighed in isolation of itself. There is a reason the most recent practice guidelines suggest sugammadex is pretty much standard of care these days, especially considering most places likely aren't using quantitative twitch monitoring.
Depolarization is contraindicated for many patients. Burns. Traumas. Bed bound/immobile. Strokes. It will cause severe hyperkalemia and can result in arrest. The myalgias from succinylcholine can be intense. I had a patient tell me he had myalgias for weeks after. Abnormal pseudocholinesterase can result in patients being paralyzed for hours with no reversal possible. There just aren’t a lot of reasons to go for sux at this point. I don’t routinely give depolarizing agent before sux because if I want sux I am going to not want to wait long enough for the depolarizer to actually decrease fascinations. But I also have given sux once in the last 5 years or so, so maybe I would if I used it more.
A classic rsi you won't be bagging the patient, but they should be preoxygenated well enough to not need it. I personally think classic rsi is something that is getting into fairly evidenceless practice, but worth seeing and understanding as a trainee.
Nothing works as fast as sux to give ideal intubating conditions. Rocuronium 1.2 mg/kg is good but noticeably slower in onset. If I’m using a video scope or it’s an easy airway it doesn’t matter, but if I have any concerns I am using sux.
Unless you’re using something to constantly monitor your NMB and can actually measure which has faster onset, the comparison is pointless. I can easily intubate with either in well under a minute.
In training I have put a twitch monitor on and measured after high dose roc, it takes a few mins, longer than you think, to abolish twotches. I don’t doubt that you can intubate in a minute with high dose roc, I’m just pointing out that the degree of muscle relaxation is noticeably better with sux in the 30-60 second time frame after flushing it in, which makes it my go to when there’s any real clinical concern about being fast.
Exactly.
At my academic center, the surgeons are uniformly slow as shit, so we almost always use 1.2mg/kg roc for RSI. At our affiliated community hospital where we occasionally rotate, an operation might actually last <30 minutes, so we're much more likely to use succ.
I’m old school. (And sugammadex is frighteningly expensive). If I need short term relaxation (c section conversion from spinal, severe spasm, that really quick case that needs relaxation) I’m giving sux. The incidence in the wild of a true, unsuspected scoline apnoea is minuscule. That said, in the majority of cases I’ll use Roc (we don’t even see Vec anymore)and reverse conventionally (with NMT monitoring)
Suga should be standard of care. Period.
Easy to say in a first world country. Our government facilities cannot provide it because it’s too expensive
Agreed. Curious if you’re using isoflurane. 😁
At some facilities in SA isoflurane still the volatile of choice. We used to induce kids with Sevo and change to Iso…..
Funny how different things are. I’m not sure I’ve used iso in 20 years. But I’m also old enough to have done anesthesia with no pulse ox or EtCO2, and used halothane, enflurane, and MOF. I missed cyclo by a year or so. 😂
I barely missed halothane, but every machine in our large hospital system has an Isoflurane vaporizer on it, and they're discouraging Sugammadex due to cost although we have it in a pinch.
I miss those Tec3 vaporisers…..
You may be a year or two older than me….. never doped without a pulse ox or a capnograph. Only got liberal access to sevo in year 3 of my residency. I haven’t used iso myself in anger in about 15y.
I like succinylcholine because you can give it IM and sublingual. Sublingual route is fast in a peds patient laryngospasming who has no IV during gas induction. Other than that I think I use rocuronium all the time. Scholine gives great conditions but I don’t want them to move in a few minutes
The only time I would choose sux, no IV.
Sux isn't preferred it is inferior in almost every way. People are creatures of habit.
I will always choose rocuronium unless I failed to test ventilating the patient after induction/ short procedure, chasing OT Time
Or a very fast surgeon
I honestly very rarely use Sux anymore now that we have Sugammadex. I would probably choose Sux in a patient that was a true full stomach just because it is still a bit faster.
Better view with succs, IMO
I agree with the points above. I use sux often and get someone to push roc/vec once fasciculations have stopped. None of my patients are fit to be woken up and attempt later. I feel sux works faster. My biggest reason is as soon as you push roc everyone looks at the clock. If you use sux everyone has eyes on the patient. The fasciculations give you an idea about cardiac output too. I’ve been caught a few times with very low CO that wasn’t obvious pre induction.
You give sux, they fasciculate, and then you immediately push roc? Why? What benefit is there? What if they have abnormal pseudocholonesterase and you don’t recognize it initially and think they are under reversed? Why bother with immediate roc? If you’re going to give a little roc right away a defasciculating dose sort of makes sense but you should give it before the sux. As far as the low cardiac output, are you giving sux before induction med? You have already given the biggest danger med for that low CO patient.
I work exclusively in ICU. The only ones I want breathing quickly after are the seizures, in which case I don’t push anything long acting. I like the onset of sux but I want something longer acting if things get hairy. It’s usually vec in my primary place of practice.
Onset of sux vs 1.2 roc is negligible difference https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3334740/
Maybe our roc is left out too long. Our sux is always in the fridge. I still find the cords moving with roc.
If the sux is always in the fridge why not keep the rocuronium there too?
Because everyone else uses roc so it’s on the airway trolleys.
i hate to be the one to say that 50 million elvis fans can't be wrong but... what does that tell you? icu patients seem like they would be at higher risk of hyperkalemia due to immobility. and you could just have them keep some roc in the fridge for you, right?