Well, thank you all for being here this morning. I'm honored to be a part of this panel. As Dr. Hogue said, we're going to update you on the guidelines for neuromuscular blocking agents. There have been some changes recently. I do have a couple of disclosures. Personally, I have received honorariums from Merck and Senzyme, a monitoring company, for speaking engagements. Dr. King and Dr. Van Pelt have none. Outcomes. We're going to talk today about monitoring considerations for patients who have received neuromuscular blocking drugs. We're going to talk about the updates to clinical guidelines related to the administration of neuromuscular blocking agents and clinical applications for the new guidelines to give you some take-home points. So why are we starting with monitoring? Really, my favorite topic is monitoring. We're talking about this first because at least it should be the foundation of what we're doing in our management of patients who receive neuromuscular blocking agents. Some basics. Basically, any time we're using neuromuscular blocking agents, we should be monitoring. We should be assessing where they're at throughout the process of surgery when they are paralyzed, if you will. We're going to monitor for determination of onset. Not so frequently, right? Very few of us typically monitor for onset. The most important is that when we're monitoring for assessment of recovery and we're preparing for reversal. That's truly the most important time. Not to minimize, also during surgery, we're monitoring frequently. And historically, how have we done this? Historically, we have used, and what probably most of you are using today, are subjective signs of clinical assessment. We'll go into just a little bit more detail about that. We've been using, most of you, if I ask for a show of hands, are probably still using exactly the same devices that were created in the 1970s. And I'll have some pictures here. So most of us are still relying on these subjective signs of assessment. There are newer types of monitoring available, and we're going to talk about that, that are objective monitors. Very key point here I want to make now to start with. The standard for readiness for extubation, the standard to show that you have achieved clinically relevant recovery from neuromuscular blockade is a train-of-four ratio of at least 0.9. Now, I realize that some of you in the room may not be familiar with that, and certainly most of you in the room may not have a tool or device to tell you that at the end of the case. So when we talk about our ability as providers to do what we do as far as subjective assessment goes, we're not very good. We have known this for a long time. This is an astounding study of nurses. We're all nurses. And just how well we do, even at counting, when we do a train-of-four, and we get it wrong about 50% of the time, believe it or not. And what's even more astounding is 17% in this study, 17% of assessments were off by two twitches. Now who can immediately see a reason that that's going to affect your choices in reversal and the effectiveness of your reversal if you're off by two twitches? And depending on where you're monitoring, Dr. Van Pelt's going to go into that a little bit later, you may be even further off. So this is what you guys see. Now I know I have gray hair, and I'm dating myself with this picture. If you notice the vintage pharma swag there, most of our resident students in the room may not even know what a few of these drugs are, and certainly don't remember the days when the pharmaceutical companies gave us these devices. But this is what a lot of you see. I think typically there's some pink tape around the battery case, or there's no battery case left and it's holding the battery in, and you're wishing you had a resident to ask them to stick that 9-volt to their tongue just to see if it's even working, right? So this is what we see now. Is this a monitor? Who thinks it's a monitor? Raise your hand in the room. No, it's not a monitor. You're the monitor. This is a nerve stimulator. All it does is apply an electrical stimulus to whatever nerve you choose to put it on. You're assessing that, so you're the monitor. Either tactile, you're feeling, or you're looking to count those number of twitches. Now I said just a minute ago, clinically relevant recovery from neuromuscular blockade is a train of four ratio greater or equal to 0.9. That's our gold standard, okay? How many of you have the ability to measure this on a daily basis in the OR? Yeah, very few, right? So this is an objective measurement, and what is it? So a train of four ratio is simply defined as the height, the amplitude, the strength, whatever you want to call it, of the fourth twitch divided by the first twitch. It's an objective representation of fade. It's an objective representation of residual paralysis. So if we're dividing a small number by a big number, it's always going to be less than one unless they're equal. It's not easy to, I mean, it's easy to ascertain that only a very small amount of residual paralysis is acceptable if the goal is 0.9, right? So that's train of four ratio. Our objective quantitative monitors, which are these devices, actually will tell us where we're at. It will give you that train of four ratio. This is typically what you're going to see today in the ORs. The picture on the far right, kinemiography. Study after study, it's all in the literature. How many of you have seen these? Typically they're in the top drawer of your anesthesia machine with still the rubber band around them from the manufacturer is where I see those mostly. They are nowhere close to the standard. They're unreliable. They do not give you accurate information. And really, maybe it's better than subjective methods, but most of the literature says it's questionable. So the other two pictures on the left are typically what you're going to see today and what's commercially available, which is acceleromyography, which is like your iPhone uses Newton's law, looks at acceleration, requires movement of a digit. And then the more newer devices, I would say, electromyography, are what you're going to find. You probably will see these guys in the exhibit hall. Go visit them. Check out their devices. There are several companies out there producing these. But as you can see, the EMG devices have something similar to a biz strip, if you will. That does not require motion. So the beauty of this device is your arms can be tucked and you can get a result. And as we get into where more and more of our cases are requiring tucked arms, robotics cases, we don't have access to anything but the face, which, by the way, just stop using it if you're using it. The face is the worst place to monitor because you are off typically by two twitches. You're overestimating. So the gold standard of places to monitor is the ulnar nerve, adductor pollicis, which one of the beauties of objective monitoring is it somewhat forces you to monitor where you should be monitoring. So if you're monitoring at the face, you may be overestimating by two twitches, just like I said earlier. Who thinks that can affect your choice of reversal and your effectiveness of reversal? So just Dr. Van Pelt's going to hit more on that later. So why is this important? Is this just a topic of we're saying, oh, there's new technology out there and it costs more, but it doesn't really matter? Well, yes, it does matter. And it matters a lot because your ability to assess train-of-four and assess fade specifically with your eye or your tactile assessment is limited to a train-of-four ratio of 0.4. Beyond that, you can see no difference. You are not even close to that bar of 0.9 when you look at a patient and you say this patient has four twitches and no fade. They're paralyzed. They're paralyzed. So what else do we do? Well, I know you think all my patients look like this at the end of the case, right? We've been using clinical signs since the 1950s when neuromuscular blocking agents came out. But this slide really shows that none of those meet the bar either. So the green bar is 0.9, and you can see at 0.2, a train-of-four ratio really close to where you're going to lose a fourth twitch. Almost 100% of those patients can achieve an adequate tidal volume, take a forced vital capacity breath. You can see hand grip, head lift, none of those even get close to where you should be at 0.9. And look at the steep curve at airway obstruction. So to reliably maintain a patent airway, you need a train-of-four ratio of 0.9. So what do we know? We know that clinical signs don't work. The best you can get from assessing all of the clinical signs, the patient that can hold their hand up on that bottle is about a 0.7. We know that things have changed. Our viewpoint of what muscles are important has changed drastically. If I ask you, most of you would say that the most important muscle for being ready to extubate would be the diaphragm. That's not really true. The most important muscles are right here. The pharyngeal muscles are the muscles that are protecting your airway, allowing you to maintain a patent airway, and allowing you to swallow, which is also preventing aspiration. Because if you can't swallow, where's all that spit going? It's going right down in the lungs. And you need a train-of-four ratio of 0.9 to be able to reliably protect your airway and swallow. So that's where 0.9 came from. So quickly on reversals. So today, we're specifically going to—you have two choices, unless you're using cis-atricurium, the benzo-isoquinolone. Say that really quickly. For aminosteroidals, rocuronium, vecuronium, you have two choices. You only have one choice. I said that wrong before when you're using benzo-isoquinolones. So how do these work? They are different. I don't have time to get deep into the physiology of this. But when we're using neostigmine, it's really an elaborate game of musical chairs, right? Neuromuscular blocking drugs are attached to post-tetanic nicotinic receptors. They're actually jumping on and off. We think that they're just there blocking them, and they stick there, but they're actually hopping on and off. We give neostigmine, we increase acetylcholine, that floods the junction, and then there's more chances of that sitting in a chair versus your blocking agent, then the blocking agents go out to the vascular system, hopefully, if you have a concentration gradient, and are eliminated. So GammaNex works entirely different. Whatever makes it to the junction, it works in the vascular system, where it encapsulates neuromuscular blocking agents, fecuronium, rocuronium, creates a massive concentration gradient so that then we all know the direction of concentration gradients, where they flow, then your neuromuscular blocking agent flows out and is gone and eliminated, and we all know how fast that works. Why are we talking about this today? So recently, I get asked all the time, if this is so important, why aren't there guidelines? Well, just recently in February, the ASA published new practice guidelines for the management of neuromuscular blocking. Dr. Van Pelt's going to talk about APSF guidelines, Daniel's going to talk about our new guidelines, but the new guidelines say, if you are delivering a drug that is a neuromuscular blocking agent, you should be monitoring, and you should be using quantitative monitoring. For the first time, now we have guidelines to say, you need to do the right thing. It also gives us guidelines for reversals. One of the things that may be news, and maybe it's evidence that you can take back to your pharmacist, to your people who are purchasing monitors, is using these studies, but for the first time, now we have a recommendation that says, unless you are in a situation of shallow blockade, which means four twitches, no visible fade, you should not be using neostigmine. You should be waiting until you get to that point to reverse. So basically, for those of you who don't have access to GammaDex, may the fourth twitch be with you, okay? So four twitches, no visible fade, or you're using quantitative monitoring, objective monitoring, and you document that you have a train-of-four ratio of 0.4, that's the only time you should be using neostigmine. The flip side beauty of this, if you have objective monitoring, and you confirm that you do have a train-of-four ratio of 0.9, you now have no legal, ethical, moral reason, clinical reason, to give reversal at all. You have objectively shown that you've achieved the gold standard for readiness for extubation. So what about data? I know you're still like, okay, yeah, you're just saying that, it's going to cost money, it's going to take more effort. This is a first study, this Weigel study that was done, where they combined quantitative monitoring with a protocol for reversal agents that was just what I described, and they had a decreased PACU length of stay, they had reduced pulmonary complications. An ICU admission cost anywhere, I've seen the studies, from $40,000 to $70,000. If that is a return to the hospital after going home, and a Medicare patient, because of a post-op pneumonia that maybe you contributed to, I contributed to, who gets paid? No one. So when we're talking about the cost of monitors and the cost of additional agents, how many does it take in a year to prevent? How many complications do you have to prevent at $50,000, $60,000 to pay for monitors that cost a few grand, and maybe $100 difference in drugs per patient? So it doesn't take much that you can see. So really, where we're at here is, and I'm going to kind of go beyond this in the amount of time we have left, I want to give you time for questions later, but we're at a point where the data now shows that by doing the right thing, spending a little money on the front end, and doing what the data says we should be doing, what the evidence says this is it, and we now have guidelines to support it, you can save money and improve outcomes. It's a no-brainer. We tend to not like change, and I think that's one of the biggest barriers. So we have to stand up and see change as not change, but innovation. Innovation is just change that we like. That's all it is. So I'm going to turn this over to Dr. Van Pelt, who will give us some real-life clinical scenarios. Good morning, everyone. Can you hear me okay? Perfect. Thank you, Dr. Flowers. I'd like to start this presentation off by asking the audience, what would you expect if you were the patient undergoing a surgical procedure and being administered a neuromuscular blocking agent, or better yet, perhaps maybe this is one of your loved ones, your parents who are elderly and at higher risk for residual neuromuscular blockade. I like to use the mouse. So the goal of my presentation really today is to bring to you everything that Dr. Flowers so eloquently described to you and just bring it to life and apply it in a real clinical scenario, a case report of an elderly patient who is 79 years old, who is a male whose status posts an exploratory laparotomy at 2 a.m. in the morning. And so this is how the story begins. So while a lot of the information that I'll be sharing with you is certainly repetition, that is intended, and our goal is to really just apply this to a clinical case scenario. So we all know that making a differential diagnosis of residual neuromuscular blockade is not necessarily easy, particularly because there are many factors to consider when you're thinking about this when a patient has respiratory decompensation in the PACU. So as is the case for this patient who presented to the PACU without oxygen because the OR was right around the corner from the PACU, he arrived with a low saturation of 88%. He was arousable to tactile stimuli, and at that point, they applied the nasal cannula oxygen. He continued to desaturate a little bit, so they then exchanged the nasal cannula with a face mask, and his oxygen saturation came up to 94%. So I'll pause there and state that this has likely been all of us in the past at one point in time and placing the oxygen was absolutely the right thing to do. But we did set this patient up for desaturation right because upon arrival he had not had oxygen. We know that transporting without oxygen with these risk factors that are listed there are predictors for desaturation. The patient in the case had two of those risk factors so we certainly put him at risk. The fact that he has recovered is not necessarily reassuring either right. We place the oxygen because we know from this seminal seminal article published in 2004 in the chest magazine that supplemental oxygen can certainly mask the ability of pulse oximetry to detect hyperventilation. However in this case after PACU handoff the anesthesia provider leaves to go back to the operating room and the patient continues to desaturate back down less than 88 percent. The patient has decreased respiratory effort now tachycardic and hypertensive. So the PACU nurse calls the anesthesia professional who's covering and come to come see the patient. So of course a number of things need to be considered when somebody is arriving with acute desaturation. We appreciate that the anesthesia professional is going to be looking at comorbid conditions the types and the amounts of narcotic that this patient received during the procedure. And of course looking at documentation related to the neuromuscular antagonists that were administered and extubation criteria that this anesthesia professional utilized. So we're going to focus on the latter part of that. So we'll take a look at the chart and what does the chart say. Documentation in the chart reads total dose of rock uranium was a hundred and eighty milligrams which makes sense perhaps a hundred milligrams for a rapid sequence induction and then about 20 every half hour to redose throughout the case to keep the patient fully relaxed. Full reversal was administered neostigmine five milligrams with glycopyrrolate zero point eight milligrams. The trachea was extubated after a train of four recovery four out of four without fade sustained tetanus and adequate minute ventilation. So again at first glance all this documentation seems very appropriate. So what happened here as they say in real estate when you're looking for a new home location location location while location matters here when they looked we can see that they placed the stimulation electrodes on the facial nerve. And as we just heard this provided a false sense of recovery as Dr. Flowers had said and I'm going to say a train of four ratio four to four is equivalent to two or less than two if you use the owner nerve. So facial nerve stimulation evaluation of the eye muscle twitches has been shown to be unreliable and it's actually associated with a five fold increase of incidence and severity of residual paralysis in the PAC you in addition has been reported to be approximately 52 percent incidence of residual paralysis in the recovery room when people have used this subjective way of looking at the eyebrow responses so it is for this reason that the current literature and the ASA guidelines as Dr. Flowers has mentioned as well as the APS F guide practice guidelines recommend the use of the owner nerve or a doctor police's muscle for the train of four monitoring. It is the gold standard. In this case the patient's arms are out for an exploratory laparotomy so it's really and we're really unsure when looking at this anesthesia record as to why they utilize the facial nerve perhaps fatigue tired quick quick case they thinking it's going to be you know it's a it's a rapid sequence induction and they placed it on the facial nerve. But what I will share with you is that many of us do cases that we don't have access to the owner nerve and with the new technology we lot of us probably don't have that either. So when the owner nerve or the doctor policies is unavailable the next best site for evaluation is the posterior tibial nerve which will really be able to be safely accessed and quite frankly this is one that I used relatively often in my clinical practice because I specialize in neuro anesthesia so a lot of the patients are prone and arms are at the side and yes I have to actually leave the head of the bed and walk around to the bottom and check my twitches. What we do know about that and there has been several studies that compared the posterior tibial to the owner nerve stimulation and they have found some rapid recovery of the posterior tibial versus on the great utilizing the great toe versus the owner. So again we really do come back to the fact that ultimately when we have access to the arms at the end of the case the recommendation is pre reversal that will do our assessment on the addictor policies or the owner nerve and prior to administration of our reversal and then ultimately after to look at the impact and the outcome of our reversal agents. So next looking at the interoperative assessment of training for recovery as this individual did using sustained tetanus. Now Dr. Flowers mentioned earlier when the anesthesia providers subjectively assesses the trainer for response with the use of nerve stimulation they're not reliably able to identify that trainer for ratio that exceeds point four. So again this means that the amplitude of the fourth twitch is only the amplitude of the first twitch. So the train of ratio in that scenario that I just presented to you would be point five and we perceive this as equal for twitches. So when using the qualitative peripheral nerve stimulator they say that the trainer for ratio between the point four and the point nine is referred to the zone of blind paralysis. So the again the main benefit of the quantitative nerve stimulator is that it can reliably and quantitatively measure the train of four ratios between that whole entire range that we consider the blind paralysis. When this patient in the recovery room was actually objectively monitored with a quantitative monitor to assess for residual neuromuscular blockade it was found that they had a zero point three six or a point four trainer for ratio. So you can see that this patient's symptomatology was associated with a residual neuromuscular blockade. So again it is for this reason that the gold standard is that when we are administering neuromuscularly blocking agents that we use a quantitative monitor versus a qualitative or assessment peripheral nerve stimulator. Dr. Flowers had mentioned this and I have this up here because a lot of us have trained in the maybe 80s 90s and before 2005 but all of us really have memorized up until most recently that that point seven was the number that we were looking for but we do know now that the data strongly supports that point nine trainer for ratio. So last but not least as it relates to the documentation of the sustained tetanus and adequate minute ventilation we know as mentioned earlier that at this point with the sustained tetanus and adequate minute ventilation that this patient actually had 75 percent or greater other receptors still occupied. Now taking a look at the reversal agent that this clinician used and the dosing that was utilized the chart indicated that they used a full reversal of neostigma five milligrams like a glycopyrrolate point eight which is certainly an appropriate paired dose. However what we do know about utilizing high dose neostigma mean which is defined as greater than 60 mikes per kilo which we just take a step back and think about what that dose might be for an average 70 kilogram patient. That's forty two hundred mikes or four point two milligrams and we know that not all of our patients are an average silly 70 kilograms but there are data to support it and I have cited one that is frequently from the frequently cited from a study that was conducted at a hospital based registry of close to 50 thousand patients who received an intermediate neuromuscular blocking agent. The authors conclude that neo stigma reversal was associated with a dose dependent increase in risk for pulmonary complications. And the one thing I want to point out is that when they did an exploratory data analysis further in this study it does suggest that the proper use of neo stigma guided neuromuscular transmission monitoring results can help eliminate post operative respiratory complications associated with these intermediate neuromuscular blocking drugs that were used. We know this patient what we know about this patient is based on everything that I've shared earlier is that they utilize the facial nerve for monitoring when they should have utilized the ulnar nerve. It would have if had they actually taken the monitor from the ulnar nerve and placed it I'm sorry from the facial nerve and placed it on the ulnar nerve. You would have seen that this patient would have had a deep or moderate neuromuscular blockade. So in this patient they utilize neo stigma mean and again so gamet X may not have been available. They should have waited and I love that line. May the fourth twitch be with you. Certainly they should have waited until that patient had a minimal depth of neuromuscular blockade and again using the ulnar nerve. And this is from again the APSF guidelines recommending that sugam and X is the recommended over neo stigma mean. Unfortunately this patient that I just presented to you is not alone when presenting to the PAC you with inadequate neuromuscular recovery. There was a meta analysis in 2007 that is also frequently cited that looked at 24 studies with approximately 3000 people and it revealed that these patients who received an intermediate neuromuscular blocking agent actually had trina for ratios of less than point nine. Later studies revealed that similar data points that even when reversed with neo stigma mean residual neuromuscular blockade was found in 30 to 50 percent of these patients. Now clearly we know that not all of these patients had adverse outcomes but what we do know is that when the trina for ratio is less than point nine patients are three times more likely to have an adverse respiratory events and these things that are listed here are certainly things that we would see and our complications and costs associated with everything that Dr. Flowers had mentioned. So residual neuromuscular blockade remains an unrecognized problem. While I'm not going to read to you the detail on the data on this slide you can see that internationally and within the U.S. that it demonstrates that anesthesiologists believe that residual neuromuscular blockade is a significant but rare problem. These data led to the Anesthesia Patient Safety Foundation collaborative panel on residual neuromuscular blockade patient safety. And this is a panel that myself and our beloved late Mark Wallover had the privilege of serving on as representatives for the A.A.A. The APSF collaborative additionally included members from the A.S.A. anesthesiology assistants peri anesthesia nurses and hospital pharmacists. We developed and validated a tool to understand that their practices and perceptions of residual neuromuscular blockade and monitoring neuromuscular function nationally. The survey was distributed to 50,000 members of the A.S.A. A.N.A. our anesthesiology assistants and the PACU nurses who were members of Aspen. We ended up with close to 3000 participants which was a five point seven percent response rate. While there were many data points that we collected I just want to share with you and emphasize that what I have listed here which is only two should say two thirds of the participants believed that residual neuromuscular blockade is 10 percent or less. And we talked about the fact that those incidences are actually five times that's only 31 to 43 percent correctly identified that residual neuromuscular blockade is a significant patient safety concern a little bit more than that survey that I had previously described to you. But a fair amount of people didn't think that it was not 45 percent felt that assessing recovery of neuromuscular functioning using clinical tests and meaning a grip strength or a five second head lift or subjective means by using a peripheral nerve stimulator was appropriate. So almost half of the individuals felt it was OK. And similarly half of these participants believed that clinical tests are moderately reliable in excluding incomplete neuromuscular recovery. So these survey results emphasize the need for the A&A and other national anesthesiology associations and foundations to disseminate the evidence that we're sharing with you today make recommendations and have supporting practice documents that can be our guiding principles our North Star our gold standard for our evidence based practice. So next Dr. King will summarize the new A&A practice document. Thank you. Thank you Dr. van Pelt. Good morning. It's great to be with you. My goal of being here and part of this panel is to really pull forth the great work that's going on in the perfect professional practice division within our national association. They in a practice committee really bears responsibility to surveil and address issues just like these that are related to work environment practice management and importantly patient safety and make recommendations for improvements to the board of directors. And we're going to share those recommendations with you today as we talk about how we incorporated these into our A&A practice documents and give you something to take home and affect your practice and hopefully improve patient outcomes as the incoming practice chair. I'm going to outline for you our process of incorporating what doctors van Pelt and Dr. Flowers so well articulated into our practice document which you can scan and open here using this QR code. It's titled airway management use of succinylcholine or rocuronium practice considerations and you can follow along. This was a document that was originally adopted in 2016 and since then has underwent ongoing review as part of our regular process. Obviously since that time the emerging evidence of Pseudogamma dex has come into full play in clinical practice and recently published guidelines that we mentioned in January of this year have really prompted encouraging encouraged us to formally revise this considerations document for the A&A membership. As a committee and amazing staff we have astutely proposed and reviewed draft revisions utilizing a systematic process including an open comment period by the membership back in May of this year. The revised document has now met board approval. I'm excited to announce that this very annual Congress. So what you're seeing if you scan this code or you look at a professional practice manual that's housed on the A&A website is the most current version of this document that was just recently approved within hours of this session. We carefully reviewed your valuable and sincerely appreciated comments alongside recent high quality evidence and we incorporated relevant changes. Specifically we updated the position statement of this document to assess comorbidities like end stage renal disease and contraindications prior to the administration. We also highlight the development of policies for departments and health systems by which these practice considerations are not intended to replace. So that's very clear. We are not seeking to substitute local policy or departmental policy. We reviewed literature to confirm similarity and onset of succinylcholine at one point two milligrams per kilogram and succinylcholine at one point two milligrams per kilogram and high dose rock uranium at one point five milligrams per kilogram for rapidly securing the airway and we felt there was sufficient evidence to validate similarity of onset but more specifically and more importantly produce similar intubating conditions. As a point of clarification in the document benzyl isoquinol selenium or cesatricurium as an example, are not proposed for rapid sequence intubation. Rather, we're proposing this for using if needing to reparalyze a patient after Sigamidex has recently been administered. We inserted the reported use of Sigamidex in end-stage renal disease patients in which caution should be exercised, given it has not been formally studied, and guidance is limited at this time. We corrected the use of the terms depolarizing and nondepolarizing to make sure language is clear in the document. And we provided an evidence-based statement regarding anaphylactoid and anaphylaxis. Because although it is not the original intended purpose of this document, we agree that this has high relevance to the topic being discussed. So as we work through this document in sequence to inform you what is new to support your decision-making in clinical practice, you'll find in the introduction that as Sigamidex has been instituted in practice, facilities like freestanding GI, ambulatory surgery, and office-based settings have garnered support in this document in the decision to potentially forego the sole MH-triggering agent likely on their formulary, which typically is sexenylcholine. Thus, this can remove and mitigate the implicated need for dantrolene. We found that this was really important among the membership to have that supportive statement. In reviewing the position statement in this document, we maintain that it is a practice considerations document. What that means by definition is that it is not a practice guideline and it is not a standard. A practice considerations document is one that's intended to provide assistance and resources related to current or emerging aspects of nurse anesthesiology practice. And within the position, we endorse formal support for the use also of rocuronium and Sigamidex combination as an alternative, a feasible alternative to sexenylcholine for emergent airway management by providing complete reversal of neuromuscular blockade and limiting the need for a potentially prolonged ventilation. This figure within the document you'll find highlights considerations and decision points for facilities and nurse anesthesiologists when determining which neuromuscular blocking agent to have available in the anesthetizing location. Sexenylcholine on the left has historically been the agent of choice for managing difficult and emergent airway issues, but clearly concerns as an MH-triggering agent and thus necessitates the accessibility to a stockpile of dantrolene as M-House suggests. Research has shown us no difference in intubation conditions when comparing two sexenylcholine with both drugs demonstrating equivalent first attempt intubation success across multiple studies. However, if utilizing rocuronium as an alternative, the calculated availability of a full reversal dose is necessary to have on hand, and that's something we want to emphasize because it may not be often that you have a questionable airway and you're acquiring the 16 milligram per kilogram dose for complete reversal to have on hand in the operating room should that situation transpire. As you can see, equipment to secure the airway and provide ventilatory support is required in both of these scenarios. Though pseudocholine esterase deficiency is listed as just one major contraindication, we know there are several others to consider when preparing for the use of sexenylcholine. Sexenylcholine also has known adverse reactions that are inclusive of things like myalgia, hyperkalemia, bradycardia, those that are listed here on this document. Recovery may be unpredictable, and because it is a triggering agent for malignant hyperthermia, M-House recommendations include the stocking minimum of 36 vials of dantrium or three vials of ryanodex at more than twice the cost and half the shelf life. And we know that is an important consideration for our CRNAs who are working in those freestanding facilities and influences purchasing decisions as well as clinical decision making. As mentioned and as points of further emphasis, when it comes to rocuronium and sexenylcholine and selecting for these agents, we want to point out that research demonstrates no difference in first attempt intubation success in these agents. And we reviewed multiple meta-analyses, randomized control trials, and high-level studies to draw that determination. The risk for anaphylaxis should be considered not only for sugamidex but also our neuromuscular blocking agents. And the full reversal dose should be calculated and, again, be readily available in the facility. And that's a 16 milligram per kilogram dose based on actual body weight. So that could be anywhere between six and eight vials of sugamidex to have on hand at the anesthetizing or airway intervention location. When it comes to non-depolarizing drugs like rocuronium, we have historically utilized neostigmine after approximately 40% of neuromuscular function has returned. We know it has a peak onset of about five minutes and a duration of action between 0.5 and four hours. Unfortunately, this has been associated also with several negative cholinergic side effects, right, like bradycardia, hypotension, GI upset. And it's rarely indicated or useful in those emergent situations because of the timings that are indicated on this slide. Sugamidex, on the other hand, for reasons that we've described to you today, is safe and effective even in pediatric populations. And it is recommended for all levels of neuromuscular blockade, whether that be deep, moderate, or a shallow depth, whether it is produced by rocuronium or vacuronium as determined by objective monitoring. So I see this often in the clinical setting where there's no monitoring at all and we're just giving an entire vial at the end of the case and trusting that we'll have reversed the patient. And that's just not simply the right thing to do. So not your assumption. You are the monitor. You know, deliver that safe anesthetic and outcome for your patient. The recommended dosing is provided for your guidance in this document. Now that's based on actual body weight. We provide a dose of four milligrams per kilogram at one to two twitches or two milligrams per kilogram at two or more twitches if rocuronium or vacuronium were administered. Notably, reversal of high-dose rocuronium with that 16 milligrams per kilogram of Sugamidex is significantly faster than waiting for the spontaneous recovery from succinylcholine. So that's why we're proposing the rocuronium-Sugamidex combination as a feasible alternative to succinylcholine. Finally, Sugamidex has lower incidence of adverse effects than neostigmine, making it furthermore an ideal choice. There are special considerations we have chosen to address in this document. They're outlined in greater depth than what I'll review here. But we know that Sugamidex is not metabolized and it is unchanged as it gets excreted renally with an average half-life in patients with normal renal function of about two hours. So administration of a benzyl isoquinolinium agent, like atricurium or cis-atricurium, is needed if you must reparalyze the patient after Sugamidex administration in that time period. Sugamidex may have utility in end-stage renal disease patients, but we exercise caution because there may be delayed clearance of that Sugamidex-ROC complex, which may increase the risk of hypersensitivity, anaphylaxis reactions, or recurrence of neuromuscular blockade. This has not been well or formally studied, and we need more studies to make that decision for formal use in end-stage renal disease. Hormonal contraceptive precautions are warranted. We know this is well-documented for patients who are using birth control. And anaphylaxis risk should be considered, again, not only for Sugamidex, but our neuromuscular blocking agents and truly any agent that we're administering at an anesthetizing location. We also recognize the cost-effectiveness is facility-dependent, and we don't intend to overlook that, but it should be offset by patient outcomes. And hopefully, this document and the guidelines that we've reviewed with you today give you an arsenal of support for purchasing decisions that are going on in your facilities. We know drug costs are influential, but that post-operative recovery is undoubtedly improved. So in conclusion, a ROC uronium-Sugamidex combination is a reasonable alternative to succinylcholine. And at the end of the day, we do recognize that decision-making is not always so straightforward. Collaborative decision-making should always place the needs of the patient first and focus on the best possible outcomes. So hopefully, this presentation has been helpful. We're happy to take your questions. I think we have about nine minutes or so for questions. Dan Yardshire. As you guys are coming up for questions, just a comment on follow-up. Thank you, guys. That was incredible being part of this panel. Traveling around the country talking about this, I had the same question that kept coming up, and the question was, Sugamidex has to be encapsulating something other than the muscle relaxant because my patients are so much more awake. And I quickly came to the realization that they're not more awake, they're just not paralyzed. Our context of a clinically relevant recovered patient is that of a paralyzed patient. So when it comes to dosing, I know because I see the stuff on Facebook, you should not be using Facebook advice on how you're using Sugamidex in the operating room, okay? Anecdotal methods, especially if you're using non-reliable subjective methods of assessment, will get you in trouble. Your patients will still be paralyzed. So don't use anecdotal methods of, I'm just going to give 200 to everyone because it works. You have no idea whether it's working or not. So just wanted to add that. Dr. Hogue. So this is a virtual question. Someone is asking if it's possible for the ANA to approach and maybe work with pharmaceutical organizations to increase the availability of Sugamidex, especially considering the need to have 16 milligrams per kilogram available. Has the ANA approached this, thought about doing something like this? That's what they're asking. Thank you. Yeah. So that was you, John. Thanks for that question. That is something very important that we'll plan to take a look at. We're always looking at innovative strategies. We're actually in the process of our strategic planning for the next fiscal year. We're meeting with the practice as a committee tomorrow, early morning, and we'll take that to the committee and certainly discuss it. All right. Thank you. Good morning. T.D. Carnahan from Pennsylvania. Thank you to the panel for a great and really clinically relevant discussion and presentation today. Can you talk about, or if anybody in the room knows, the medical legal implications of not administering a reversal to a patient with a trade-off ratio greater than 0.9? Just personally in my practice, I always give reversal every time. I think the new guidelines are a step in that direction. With the textbook definition and research and every bit of evidence saying that the benchmark, the gold standard that you've achieved clinically relevant recovery, and you can reliably show that you can reduce or not have complications in general, you can always have complications, but you can at least meet the benchmark, I think you're in a safe place now to do that because you've met the standard. Now if you're not using objective methods, you don't know, so you certainly can't do that. So I think if you only have subjective methods of assessment, absolutely, you should be giving reversal to everyone. But if you can document that you have achieved and you are using objective monitoring, the recommendations say now there's no need for reversal, which is a cost savings. Thank you. Good morning, Paul Packard. My opinions reflect my opinions only and do not reflect the AANA board of directors or the AANA from North Carolina. So something that I'd like to see incorporated is the ISMP recommendation. I know this was critical for me whenever I got Sigametex as a director in the hospital. Their recommendation that the best practice is to have any and all reversal agents immediately available at the bedside. And Sigametex is really a superior reversal agent. I mean, if you give an intubating dose of rocuronium, you can't reverse the patient with neostigmine, so ultimately it's not a reversal agent to have available. So that's certainly an argument you can use and make, especially when you're including your pharmacy in that. Most pharmacies use the ISMP, and you should bring that up to them, and they'll be like, oh, okay, yeah, I guess it is a reversal agent. So you can use that to your advantage, and I certainly did that. The other thing that comes up for me is the whole oral contraceptive battle, I guess. And if we go back to Nursing 101, discharge planning starts on admission, not when they arrive to the PACU. There's multiple medications besides Sigametex that interfere with oral contraceptives. We've known this for a long time. To the best of my knowledge, and please, to our expert panel, you can correct me if I'm wrong, but I'm not aware of any study that's been done on patients given multiple medications that we give within anesthesia and the effects of those multiple agents on oral contraceptives. So ultimately what I did is we put a disclaimer on our anesthesia consent that says if you're receiving general anesthesia, you're going to receive medications that may interfere with your oral contraceptives, and you approach that at the beginning, not the end, and just tell every single patient of childbearing age on oral contraceptives, this may interfere with it. You need to choose an alternate method of birth control. So what are your thoughts on that? Yeah, I think that's a great approach. I think as long as you're doing something, right, and you're notifying them. I know that in our system there's a trigger in Epic, but whatever electronic medical record you're using that triggers, and when you document that that drug's given, then it automatically puts that into your discharge planning. So I think that's pretty, it's a pretty easy trigger to do within your electronic medical records. But yeah, you have to be doing something, and that's a great approach. I actually write it in my anesthesia consents. We don't have it in our consent, however, when I see that the patient's on oral contraceptive, I write the whole entire thing out in the open area, discuss it with them, and have them initial it, actually. So there's several online questions. First of all, one person asked, have you ever witnessed cardiac arrest from a single dose, 200 milligrams of Sugamidex, or did you read about it in your meta-analyses reviews? There is certainly bradycardia reported, and as we mentioned, anaphylaxis, it could have been related to that. So it is reported in the literature. I will say that the incidence varies, but when it comes to anaphylaxis particularly, it's the same or less than the incidence with rocuronium. So it's really hard to determine the actual incidence of it, but yes, there are case reports. It is something to be aware of that that can occur. So, I mean, one of the things to consider as well is administration time of your Sugamidex. So that is something that I take into consideration based on the literature and the case reports that are out there of bradycardia. Okay. The next one is... Can I add one more comment on that as well, though? So we were drawing comparisons to rocuronium and Sugamidex to succinylcholine, and bear in mind that in the early 90s, succinylcholine received a black box warning for cardiac arrest, and the reason for that was related to those conditions like unrecognized muscular dystrophy, right? So just bear in mind that every single drug has a potential outcome such as that, and it weighs into decision-making on both sides.

neuromuscular blocking agents

monitoring considerations

Sugammadex

reversal

objective monitoring

train-of-four ratio

neostigmine

end-stage renal disease

comorbidities