NMB reversal agents
More things to think about with Sugammadex...16mg/kg
-Associated with increases in aPTT, PT, and INR -Be careful in patients: with coagulopathies -treated with therapeutic anticoagulation -receiving thromboprophylaxis other than Heparin and LMWH
Drug compatibility and redosing with Sugammadex
-Compatible with most IV infusion solutions (LR, D5, NS) -Make sure the line is flushed well after administering. -Physically incompatible with verapamil, ondansetron, ranitidine -recommended: wait 24 hours for readmission of Roc/Vec after reversal -Recommended to use a nonsteroidal or succinylcholine for redose after reversal.
Neostigimine (Prostigmin)
-Dose: 0.04 -0.08 mg/kg (max 5 mg) -For every 1 mg of Neostigmine mix with 0.2 mg glycopyrrolate (sometimes less). can mix or give separately. Max dose 5 mg.. Onset : 15 minutes Duration 1-2 hrs depending on twitches. Hepatic metabolism. Urinary excretion.
How to remember anticholinergic side effects.
-Hot as a hare -blind as a bat -mad as a hatter -red as beet dry as a bone
Sugammadex (Bridion)
-Modified gamma-cyclodextrin. -eight sugars arranged in a ring specifically designed to ENCAPSULATE -highly water soluble with a hydrophobic cavity large enough to encapsulate steroidal neuromuscular blocking drugs, especially rocuronium. -No real undesirable effects like anticholinesterases -Independent of depth of NMB -No effect on acetylcholinesterase or cholinergic receptors.
Physostigmine
-Tertiary amine -Only anticholinesterase that crosses BBB -Not used for the reversal of muscle relaxants. -Used to treat anticholinergic toxicity -S/s: flushing, dry skin and mucous membranes -mydriases with loss of accommodation -altered mental status -fever and urinary retention CNS-restless, shivers, agitation, disoriented.
Endrophonium (enlon) (tensilon)
-Used with atropine (crossed the BBB) due to rapid onset -Enlon plus = mixture on edrophonium and atropine together in the same vial. -Mostly ineffective when given for deep blocks -Rapid onset (1-2 min) -Short duration -Quartenary amine Dose .5 mg/kg with atropine . 7-10 mcg/kg (0.014 mg.mg of edrophonium) Duration 5-20 minutes. Enlon plus : 0.05 -0.1 mg/kg slowly over a minute.
Sugammadex reactions
-hypersensitivity (sneezing, nausea, and urticaria) -anaphylaxis *airway edema *bronchospasm *CV collapse Seen more often in higher doses and within 5 minutes of administration. Treatment : small boluses of epinephrine (10-20 mcg) titrated to response, benadryl, dexamethasone and famotidine.
Things to think about with Sugammadex
-renal failure -has no interaction with succinylcholine or benzylisoquinolines -High dose (16 mg/kg) can possibly see bradycardia (cardiac arrest), headache hypotension N/V anaphylaxis hypersensitivity (pruritic and uticaria) -hormonal contraceptives (7 days) and some antibioitcs. -Use the lowest dose possible (requires 4 mg to encapsulate 1 mg of rocuronium... usually 200 mg is adequate.
