AHFS Class:

• Neuromuscular Blocking Agents 12:20.20

Generic Name(s):

• Rocuronium Bromide

Rocuronium bromide is an aminosteroid nondepolarizing neuromuscular blocking agent.1,9,420

Skeletal Muscle Relaxation

Rocuronium bromide is used to produce skeletal muscle relaxation during surgery after general anesthesia has been induced.1,420 Rocuronium also is used to facilitate endotracheal intubation (rapid sequence and routine tracheal intubation); while slightly slower than that of succinylcholine, the onset of action of rocuronium is more rapid than that of most other currently available nondepolarizing agents.1,2,3,4,5,6,7,8

Rocuronium also is used to facilitate mechanical ventilation in the intensive care unit (ICU); however, the manufacturer states that prolonged use of the drug in this setting has not been evaluated.1 Whenever neuromuscular blocking agents are used in the ICU, the benefits versus risks of such therapy must be considered and patients should be assessed frequently to determine the need for continued paralysis.1,421 (See Intensive Care Setting under Warnings/Precautions: Other Warnings and Precautions, in Cautions.)

Compared with other neuromuscular blocking agents, rocuronium has a rapid onset and intermediate duration of action; the drug's rapid onset of effect is particularly desirable in emergency situations when rapid tracheal intubation is required.1,420,421,424 Succinylcholine traditionally has been considered the neuromuscular blocking agent of choice for rapid sequence intubation because of its rapid onset and short duration of action; however, the drug is associated with serious adverse effects (e.g., hyperkalemia, bradycardia, malignant hyperthermia).110,424 If succinylcholine cannot be used, rocuronium, which has the most similar pharmacokinetic profile, generally is recommended as an alternative.110,420,421,424 Clinical studies have shown that rocuronium can produce similar intubating conditions to succinylcholine when given in sufficient doses (e.g., at least 1 mg/kg); however, succinylcholine is more likely to achieve excellent intubating conditions and remains clinically superior to rocuronium with respect to its shorter duration of action.1,110,421

Administration

Rocuronium bromide is administered IV only.1

IV Administration

The initial (intubating) dose of rocuronium is administered by rapid IV injection; maintenance doses may be administered by intermittent IV injection or continuous IV infusion.1

For continuous IV infusion, rocuronium bromide injection should be diluted to the desired concentration (e.g., 0.5, 1, or 5 mg/mL) in a compatible IV solution (0.9% sodium chloride, 5% dextrose, 5% dextrose and 0.9% sodium chloride, lactated Ringer's, or sterile water for injection).1 The infusion solution should be used within 24 hours of preparation.1 Use of a controlled-infusion device is recommended to ensure precise control of the flow rate during continuous IV infusion of the drug.359 The rate of spontaneous neuromuscular recovery following discontinuance of the infusion is likely to be comparable to the rate of recovery following administration of a single IV injection of the drug.1

Rocuronium bromide injection should be stored at 2-8°C prior to use; the drug should not be frozen.1 Once removed from refrigeration, the injection should be used within 60 days; opened vials of the drug should be used within 30 days.1 Following dilution, the infusion solution may be stored at room temperature for up to 24 hours.1

Rocuronium should not be mixed in the same syringe nor administered simultaneously through the same needle as an alkaline solution.1

If extravasation occurs, administration of the drug should be discontinued immediately and restarted in another vein.1

Standardize 4 Safety

Standardized concentrations for rocuronium have been established through Standardize 4 Safety (S4S), a national patient safety initiative to reduce medication errors, especially during transitions of care. 249,250Multidisciplinary expert panels were convened to determine recommended standard concentrations. 249,250Because recommendations from the S4S panels may differ from the manufacturer's prescribing information, caution is advised when using concentrations that differ from labeling, particularly when using rate information from the label. 249,250 For additional information on S4S (including updates that may be available), see [Web].249,250

Dispensing and Administration Precautions

Neuromuscular blocking agents should be administered only by individuals who are adequately trained in their use and complications.1,359 For specific procedures and techniques of administration, specialized references should be consulted. Facilities and personnel necessary for intubation, administration of oxygen, and respiratory support should be immediately available whenever these drugs are used.1,359,424 In addition, a reversal agent should be readily available in the event of a failed intubation or to accelerate neuromuscular recovery after surgery.1,359,421 (See Dosage and Administration: Reversal of Neuromuscular Blockade.)

Because neuromuscular blocking agents can cause respiratory arrest, precautions (e.g., storage segregation, warning labels, access limitations) should be taken to ensure that these drugs are not administered without adequate respiratory support.425 Affixing warning labels to storage containers and final administration containers is recommended to clearly communicate that respiratory paralysis can occur and ventilator support is required.425 The Institute for Safe Medication Practices (ISMP) recommends the following wording for these containers: “Warning: Paralyzing agent—causes respiratory arrest—patient must be ventilated.”425

Neuromuscular blocking agents have no known effect on consciousness, pain, or cerebration, and should therefore be used in conjunction with adequate levels of anesthesia, and only after appropriate analgesics and sedatives are administered.1,359,421,423,424 To avoid distress to the patient, rocuronium should be administered only after unconsciousness has been induced.421,424

Dosage

Dosage of rocuronium bromide must be adjusted carefully according to individual requirements and response.1 The use of a peripheral nerve stimulator is recommended to accurately monitor the degree of neuromuscular blockade and recovery, determine the need for additional doses, and minimize the possibility of overdosage.1,421 (See Administration Precautions under Warnings/Precautions: Warnings, in Cautions.)

A reduction in the dosage of rocuronium bromide may be required in patients receiving general anesthetics (e.g., enflurane, isoflurane) that potentiate its neuromuscular blocking activity.1 Potentiation is minimal when rocuronium is administered prior to these anesthetics.1

Adult Dosage

The recommended initial (intubating) dose of rocuronium bromide in adults is 0.6 mg/kg.1 Following administration of this initial dose, neuromuscular blockade sufficient for intubation (80% or more blockade) is attained in about 1 minute (range: 0.4-6 minutes) and most patients have intubation completed within 2 minutes; maximum neuromuscular blockade generally occurs in less than 3 minutes.1 When used concomitantly with balanced anesthesia, this initial dose usually results in clinically sufficient neuromuscular blockade for about 31 minutes (range: 15-85 minutes).1 When used concomitantly with inhalation anesthetics, a longer duration of blockade is expected.1

The manufacturer states that a lower initial rocuronium bromide dose of 0.45 mg/kg may be used, which can provide sufficient neuromuscular blockade for intubation in about 1.3 minutes, maximum blockade in approximately less than 4 minutes, and clinically sufficient blockade for about 22 minutes under balanced anesthesia.1 Spontaneous recovery may occur more rapidly with this lower initial dose.1 When administration of a larger initial dose is considered necessary, the manufacturer states that rocuronium bromide may be administered in initial doses of 0.9 or 1.2 mg/kg, providing clinically sufficient neuromuscular blockade for about 58 (range: 27-111) or 67 (range: 38-160) minutes, respectively.1

For rapid sequence intubation, the manufacturer states that a rocuronium bromide dose of 0.6-1.2 mg/kg generally results in good to excellent intubating conditions in less than 2 minutes in most patients who are appropriately premedicated and adequately anesthetized.1 In clinical studies, the median dose of rocuronium bromide for rapid sequence intubation with etomidate as the induction agent was 1.19 mg/kg.110 Although a higher dose of rocuronium bromide (1.2 mg/kg) can produce a faster onset of action, higher doses do not necessarily produce better intubating conditions and may increase the duration of action.1,110

For maintenance of neuromuscular blockade during prolonged surgical procedures, additional rocuronium bromide doses may be given by intermittent IV injection when recovery of neuromuscular function is evident.1 When used concomitantly with balanced anesthesia, additional rocuronium bromide doses of 0.1, 0.15, or 0.2 mg/kg administered at 25% recovery of control T1 (i.e., 3 twitches in a train-of-four [TOF]) can be expected to provide clinically sufficient neuromuscular blockade for about 12, 17, or 24 minutes, respectively.1 Alternatively, patients may receive a continuous IV infusion of rocuronium bromide at a rate of 10-12 mcg/kg per minute to maintain adequate neuromuscular blockade during surgery; the infusion should be initiated only after early spontaneous recovery from the initial dose is evident.1 The rate of infusion should be individualized based on patient response to peripheral nerve stimulation.1 In clinical studies, maintenance infusion rates of 4-16 mcg/kg per minute were required.1 A reduction in the rocuronium infusion rate by 30-50% may be necessary approximately 45-60 minutes following the initial intubating dose if steady-state anesthesia has been induced with enflurane or isoflurane.1 Additional direct IV (“bolus”) doses of rocuronium may be necessary if the infusion is initiated after substantial return of neuromuscular function (more than 10% of control).1

Pediatric Dosage

The recommended initial (intubating) dose of rocuronium bromide in pediatric patients is 0.6 mg/kg.1 A lower initial dose of 0.45 mg/kg may be used depending on the anesthetic technique and patient age.1 Neonates tend to have lower dosage requirements than older children (2-11 years of age).1

When used concomitantly with halothane anesthesia, a rocuronium bromide dose of 0.6 mg/kg generally produces good to excellent intubating conditions within approximately 60 seconds and clinically effective blockade for about 41 minutes (in children 3-12 months of age) or 26 minutes (in children 1-12 years of age).1 When used concomitantly with sevoflurane (induction) and isoflurane/nitrous oxide (maintenance) anesthesia in pediatric patients of any age, an initial rocuronium bromide dose of 0.45 or 0.6 mg/kg generally produces good to excellent intubating conditions within 75 seconds.1

To maintain neuromuscular blockade when halothane is used as the anesthetic agent, additional rocuronium bromide doses of 0.075-0.125 mg/kg may be administered by intermittent IV injection upon return of T1 to 25% in pediatric patients 3 months of age through adolescence; doses in this range can be expected to provide clinical relaxation for 7-10 minutes.1 Alternatively, a continuous IV infusion may be initiated at a rate of 12 mcg/kg per minute upon return of T1 to 10% (i.e., one twitch present in a TOF).1

To maintain neuromuscular blockade when sevoflurane is used for induction and isoflurane/nitrous oxide for maintenance of general anesthesia, additional rocuronium bromide doses of 0.15 mg/kg may be administered by intermittent IV injection at the reappearance of T3 in pediatric patients of all ages.1 Alternatively, a continuous IV infusion may be initiated at a rate of 7-10 mcg/kg per minute at the reappearance of T2.1

More frequent administration of maintenance doses may be required in children 1-12 years of age compared with adults.1

Reversal of Neuromuscular Blockade

Neuromuscular blockade induced by rocuronium can be reversed by administering a cholinesterase inhibitor (e.g., neostigmine, pyridostigmine, edrophonium) in conjunction with an anticholinergic agent such as atropine or glycopyrrolate to block the adverse muscarinic effects of the cholinesterase inhibitor.1 Alternatively, sugammadex may be used for the reversal of rocuronium-induced neuromuscular blockade after surgery.340,342,344,346 For specific information on the uses and dosage and administration of these other drugs, see the individual monographs .

To minimize the risk of residual neuromuscular blockade, reversal should only be attempted after some degree of spontaneous recovery has occurred; patients should be closely monitored until adequate recovery of normal neuromuscular function is assured (i.e., ability to maintain satisfactory ventilation and a patent airway).1,355,356,357,358,421

Special Populations

An increased initial dose of rocuronium bromide may be required for rapid sequence induction in patients with ascites; however, doses higher than 0.6 mg/kg have not been evaluated.1 Once blockade is established, duration may be prolonged in such patients.1 (See Hepatic Impairment under Warnings/Precautions: Specific Populations, in Cautions.)

Dosage adjustment of rocuronium generally is not necessary in patients with renal impairment; however, dosage should be individualized in such patients because of wide interpatient variability.1

Because metabolism of rocuronium does not depend on plasma cholinesterase (pseudocholinesterase), dosage adjustment is not necessary in patients with reduced activity of this enzyme.1,9

Although the onset time of rocuronium may be delayed in patients with impaired circulation, larger than usual initial doses of the drug generally are not recommended; when feasible, more time should be allowed for the drug to achieve its effect in such patients.1

Substantially increased doses may be required in burn patients due to the development of resistance.1

In obese patients, the initial dose of rocuronium 0.6 mg/kg should be based on actual body weight.1 In clinical studies, patients were dosed according to actual body weight, and no substantial differences in rocuronium pharmacokinetics were observed in patients who were 30% or more above their ideal body weight.1

Contraindications

Rocuronium is contraindicated in patients with known hypersensitivity to the drug or other neuromuscular blocking agents.1

Warnings/Precautions

Warnings

Rocuronium shares the toxic potentials of the nondepolarizing neuromuscular blocking agents, and the usual precautions of neuromuscular blocking agent administration should be observed. (See Cautions in the Neuromuscular Blocking Agents General Statement 12:20.20.)

Administration Precautions

When used inappropriately, neuromuscular blocking agents can severely compromise respiratory function and induce respiratory paralysis; special precautions should be taken during and after administration of these drugs.1,359,421,424 (See Dispensing and Administration Precautions under Dosage and Administration: Administration.) The degree of neuromuscular blockade produced by rocuronium should be monitored with a peripheral nerve stimulator, particularly in patients with conditions that may potentiate (e.g., neuromuscular diseases) or cause resistance to (e.g., burns) the neuromuscular blocking effects of the drug.1

Extravasation of rocuronium may cause local tissue irritation.1 (See Dosage and Administration: Administration.)

Sensitivity Reactions

Hypersensitivity Reactions

Serious hypersensitivity reactions, including anaphylaxis, have been reported rarely with all neuromuscular blocking agents; such reactions were life-threatening or fatal in some cases.1,422 Appropriate emergency treatment should be readily available whenever these drugs are administered.1 Because of potential cross-sensitivity, rocuronium should be used with caution in patients who have experienced previous anaphylactic reactions to other neuromuscular blocking agents (depolarizing or nondepolarizing).1 (See Cautions: Contraindications.)

Other Warning and Precautions

Residual Paralysis

Residual neuromuscular blockade after cessation of neuromuscular blocking drugs can occur as a result of accumulation of the neuromuscular blocking agent (or its metabolites) or concomitant use of certain drugs.1,420,421 Use of a reversal agent should be considered (see Dosage and Administration: Reversal of Neuromuscular Blockade) and patients should be extubated only when adequate recovery of neuromuscular function is assured.1

Intensive Care Setting

Prolonged paralysis and/or muscle weakness or myopathy have been reported after long-term use of neuromuscular blocking agents to support mechanical ventilation in the intensive care unit (ICU).1,420

Continuous monitoring of neuromuscular transmission with a peripheral nerve stimulator is recommended whenever rocuronium is used in the ICU.1 Additional doses of rocuronium or any other neuromuscular blocking agent should not be administered before there is a definite response to nerve stimulation tests.1

Malignant Hyperthermia

Malignant hyperthermia is rarely associated with the use of neuromuscular blocking agents and/or potent inhalation anesthetics.420 In an animal study in susceptible swine, rocuronium did not trigger malignant hyperthermia; however, the drug has not been studied in patients with increased susceptibility to this condition.1 Because malignant hyperthermia can occur even in the absence of a recognized precipitating factor, clinicians should be vigilant for its possible development and prepared for its management in any patient undergoing general anesthesia.1

Cardiovascular Effects

Patients with conditions that prolong circulation time (e.g., cardiovascular disease) may experience a delay in the onset time of rocuronium.1 (See Dosage and Administration: Special Populations.)

Rocuronium may increase pulmonary vascular resistance; caution is advised in patients with pulmonary hypertension or valvular heart disease.1 Transient tachycardia has been reported in some patients receiving the drug.1

Conditions that May Potentiate or Cause Resistance to Neuromuscular Blocking Agents

The neuromuscular blocking effects of rocuronium may be potentiated in patients with debilitation, cachexia, or carcinomatosis or in those receiving certain concomitant drugs (e.g., enflurane, isoflurane, antibiotics, magnesium salts, lithium, local anesthetics, procainamide, quinidine).1 A reduction in rocuronium dosage may be required.1

Conditions that may cause resistance to nondepolarizing neuromuscular blocking agents include burns, disuse atrophy, denervation, direct muscle trauma, and long-term use of carbamazepine, phenytoin, or neuromuscular blocking agents.1 (See Cautions: Precautions and Contraindications, in the Neuromuscular Blocking Agents General Statement 12:20.20.) An increase in rocuronium dosage may be required.1

Neuromuscular Diseases

Patients with neuromuscular diseases (e.g., myasthenia gravis, Eaton-Lambert syndrome) may have an exaggerated response to rocuronium.1 The degree of neuromuscular blockade in such patients should be monitored with a peripheral nerve stimulator and a small test dose is recommended.1

Electrolyte Disturbances

Increased or decreased neuromuscular blockade is possible in patients with electrolyte disturbances or acid/base abnormalities receiving rocuronium.1

QT Interval Prolongation

Prolongation of the QT interval has been reported in pediatric patients receiving rocuronium and general anesthetics concomitantly.1

Extravasation

Local irritation may occur during administration of rocuronium; if extravasation occurs, injection or infusion of the drug should be discontinued and restarted in another vein.1

Specific Populations

Pregnancy

Category C.1 (See Users Guide.)

Rocuronium has been used in a limited number of pregnant women undergoing cesarean section.1 The manufacturer states that the drug is not recommended for rapid sequence induction in patients undergoing cesarean section because of possible poor or inadequate intubating conditions.1

Pediatric Use

Rocuronium has been evaluated in pediatric patients of all ages, including neonates, receiving sevoflurane and isoflurane/nitrous oxide anesthesia, and in pediatric patients 3 months to 14 years of age receiving halothane anesthesia.1 In pediatric patients receiving halothane anesthesia, transient increases in heart rate were observed following an intubating dose of rocuronium; this occurred mostly in patients who did not receive atropine.1

Although not conclusively demonstrated, there is some evidence suggesting that concomitant use of general anesthetics with rocuronium can prolong the corrected QT (QT_c) interval in pediatric patients.1

The manufacturer states that rocuronium is not recommended for rapid sequence intubation in pediatric patients.1

Geriatric Use

Rocuronium has been evaluated in geriatric patients 65-80 years of age in clinical studies.1 Geriatric patients exhibited a slightly slower onset and increased duration of neuromuscular blockade with rocuronium compared with younger adults; however, recovery times were not prolonged.1 Other clinical experience has not revealed age-related differences in response among geriatric patients receiving the drug; however, the possibility of greater sensitivity of some older patients cannot be ruled out.1

Hepatic Impairment

Rocuronium should be used with caution in patients with clinically important hepatic impairment since the drug is eliminated principally by the liver; duration of neuromuscular blockade and recovery times may be prolonged in such patients.1 Incomplete neuromuscular blockade has been reported in patients with cirrhosis, which is consistent with the increased volume of distribution observed in patients with substantial hepatic impairment.1 (See Dosage and Administration: Special Populations.)

Renal Impairment

Rocuronium is not substantially eliminated by the kidneys; the duration of neuromuscular blockade induced by the drug is not expected to be prolonged in patients with renal impairment.1 (See Dosage and Administration: Special Populations.)

No substantial differences in pharmacokinetics have been observed in patients with renal impairment relative to those with normal renal function.1

Common Adverse Effects

Adverse effects of rocuronium observed in 2% or more of patients in clinical studies were transient hypotension and hypertension.1

Concurrent administration of some drugs, including general anesthetics (e.g., enflurane, isoflurane), antibiotics (e.g., aminoglycosides, polymyxins), lithium, succinylcholine, magnesium salts, procainamide, and quinidine, may affect the neuromuscular blocking activity of rocuronium.1 For additional information on potential drug interactions of rocuronium, see Drug Interactions in the Neuromuscular Blocking Agents General Statement 12:20.20 .

Anticonvulsants

Resistance to the neuromuscular blocking effects of rocuronium has been observed in patients receiving long-term phenytoin or carbamazepine therapy.1 Higher rocuronium infusion rates may be necessary in such patients.1

Anti-infective Agents

The possibility that some anti-infective agents (e.g., aminoglycosides, bacitracin, polymyxins, vancomycin, tetracyclines) may enhance the neuromuscular blocking effects of rocuronium should be considered.1 A reduction in the dose or infusion rate of rocuronium may be necessary in such patients.1

General Anesthetics

Enflurane and isoflurane may prolong the duration of initial and maintenance doses of rocuronium, with maintenance doses affected to a greater degree (prolonging the duration by 30-50%).1 Under enflurane or isoflurane anesthesia, infusion rate requirements of rocuronium are reduced by approximately 40%.1 Spontaneous recovery of neuromuscular function is prolonged by enflurane and isoflurane, but induced recovery (with a reversal agent) is minimally affected.1

A reduction in the rocuronium dose and/or infusion rate may be necessary depending on when the drug is administered in relation to the inhalation anesthetic.1 Potentiation is minimal when rocuronium is administered prior to the inhalation anesthetic.1 (See Dosage and Administration: Dosage.)

Lithium

The neuromuscular blocking effects of rocuronium may be enhanced by lithium.1 A reduction in the dose or infusion rate of rocuronium may be necessary.1

Local Anesthetics

The neuromuscular blocking effects of rocuronium may be enhanced by local anesthetics.1 A reduction in the dose or infusion rate of rocuronium may be necessary.1

Magnesium Salts

The neuromuscular blocking effects of rocuronium may be enhanced by magnesium salts.1 A reduction in rocuronium dosage may be necessary.1

Nondepolarizing Neuromuscular Blocking Agents

Interactions have not been observed between rocuronium and other nondepolarizing neuromuscular blocking agents.1

Procainamide

The neuromuscular blocking effects of rocuronium may be enhanced by procainamide.1 A reduction in the dose or infusion rate of rocuronium may be necessary.1

Propofol

Propofol has no apparent effect on the duration of neuromuscular blockade induced by rocuronium or on subsequent recovery of neuromuscular function.1

Quinidine

The neuromuscular blocking effects of rocuronium may be enhanced by quinidine.1 A reduction in the dose or infusion rate of rocuronium may be necessary.1

Recurrent paralysis has occurred when quinidine was administered during recovery from muscle relaxants.1

Succinylcholine

Prior administration of succinylcholine has been reported to increase the duration of neuromuscular blockade produced by rocuronium; the effects of succinylcholine should be allowed to subside before administration of rocuronium.1

Description

Rocuronium bromide is a nondepolarizing neuromuscular blocking agent that produces pharmacologic effects similar to those of other nondepolarizing neuromuscular blocking agents.1,9 (See Pharmacology in the Neuromuscular Blocking Agents General Statement 12:20.20.) Rocuronium produces skeletal muscle relaxation by causing a decreased response to acetylcholine (ACh) at the myoneural (neuromuscular) junction of skeletal muscle.1,2 The drug exhibits a high affinity for ACh receptor sites and competitively blocks access of ACh to the motor end-plate of the myoneural junction, and may affect ACh release.1

Rocuronium has a rapid onset and intermediate duration of action.1,420,421,424 The onset of action is slower than that of succinylcholine but more rapid than that of most other currently available nondepolarizing agents.2,3,4,5,6,7,8 Rocuronium is metabolized to a less active metabolite, 17-desacetyl-rocuronium, that is rarely detected in the plasma and urine and is eliminated principally by the liver.1

Rocuronium exhibits transient increases in heart rate and minimal histamine-releasing activity at usual therapeutic doses.1

Advice to Patients

Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1

Importance of informing clinician of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses (e.g., cardiovascular disease, neuromuscular disease).1

Importance of informing patients of other important precautionary information.1 (See Cautions.)

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer's labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

1. Hospira. Rocuronium bromide injection prescribing information. Lake Forest, IL; 2014 Feb.

2. Puhringer FK, Khuenl-Brady KS, Koller J et al. Evaluation of the endotracheal intubating conditions of rocuronium (ORG 9426) and succinylcholine in outpatient surgery. Anesth Analg . 1993; 76:904-5.

3. Huizinga AC, Vandenbrom RH, Wierda JM et al. Intubating conditions and onset of neuromuscular block of rocuronium (Org 9426); a comparison with suxamethonium. Acta Anaesthesiol Scand . 1992; 36:463-8. [PubMed 1321542]

4. Magorian T, Flannery KB, Miller RD. Comparison of rocuronium, succinylcholine, and vecuronium for rapid-sequence induction of anesthesia in adult patients. Anesthesiology . 1993; 79:913-8. [PubMed 7902034]

5. Bartkowski RR, Witkowski TA, Azad S et al. Rocuronium onset of action: a comparison with atracurium and vecuronium. Anesth Analg . 1993; 77:574-8. [PubMed 8103649]

6. Cooper R, Mirakhur RK, Clarke RS et al. Comparison of intubating conditions after administration of Org 9246 (rocuronium) and suxamethonium. Br J Anaesth . 1992; 69:269-73. [PubMed 1389845]

7. Mirakhur RK. Newer neuromuscular blocking drugs: an overview of their clinical pharmacology and therapeutic use. Drugs . 1992; 44:182-99. [PubMed 1382013]

8. Agoston S, Vandenbrom RHG, Wierda JMKH. Clinical pharmacokinetics of neuromuscular blocking drugs. Clin Pharmacokinet . 1992; 22:94-115. [PubMed 1551294]

9. Organon, West Orange, NJ: Personal communication.

110. Tran DT, Newton EK, Mount VA et al. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev . 2015; :CD002788. [PubMed 26512948]

249. ASHP. Standardize 4 Safety: pediatric continuous infusion standard. Updated 2024 Mar. From ASHP website. Updates may be available at ASHP website. [Web]

250. ASHP. Standardize 4 Safety: adult continuous infusion standard. Updated 2024 Jun. From ASHP website. Updates may be available at ASHP website. [Web]

340. Merck & Co., Inc. Bridion^® (sugammadex) injection prescribing information. Whitehouse Station, NJ; 2016 Oct.

341. Society of Critical Care Medicine and American Society of Health-System Pharmacists. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Am J Health-Syst Pharm . 2002; 59:179-95. [PubMed 11826571]

342. Blobner M, Eriksson LI, Scholz J et al. Reversal of rocuronium-induced neuromuscular blockade with sugammadex compared with neostigmine during sevoflurane anaesthesia: results of a randomised, controlled trial. Eur J Anaesthesiol . 2010; 27:874-81. [PubMed 20683334]

343. Khuenl-Brady KS, Wattwil M, Vanacker BF et al. Sugammadex provides faster reversal of vecuronium-induced neuromuscular blockade compared with neostigmine: a multicenter, randomized, controlled trial. Anesth Analg . 2010; 110:64-73. [PubMed 19713265]

344. Jones RK, Caldwell JE, Brull SJ et al. Reversal of profound rocuronium-induced blockade with sugammadex: a randomized comparison with neostigmine. Anesthesiology . 2008; 109:816-24. [PubMed 18946293]

345. Lemmens HJ, El-Orbany MI, Berry J et al. Reversal of profound vecuronium-induced neuromuscular block under sevoflurane anesthesia: sugammadex versus neostigmine. BMC Anesthesiol . 2010; 10:15. [PubMed 20809967]

346. Lee C, Jahr JS, Candiotti KA et al. Reversal of profound neuromuscular block by sugammadex administered three minutes after rocuronium: a comparison with spontaneous recovery from succinylcholine. Anesthesiology . 2009; 110:1020-5. [PubMed 19387176]

355. Bevan DR, Donati F, Kopman AF. Reversal of neuromuscular blockade. Anesthesiology . 1992; 77:785-805. [PubMed 1416176]

356. Srivastava A, Hunter JM. Reversal of neuromuscular block. Br J Anaesth . 2009; 103:115-29. [PubMed 19468024]

357. Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg . 2010; 111:129-40. [PubMed 20442261]

358. Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg . 2010; 111:120-8. [PubMed 20442260]

359. Institute for Safe Medication Practices. Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. ISMP Medication Safety Alert! Acute Care edition. Horsham, PA; 2016 June. From ISMP website [Web]

420. McManus MC. Neuromuscular blockers in surgery and intensive care, part 1. Am J Health-Syst Pharm . 2001; 58:2287-99. [PubMed 11763807]

421. McManus MC. Neuromuscular blockers in surgery and intensive care, part 2. Am J Health-Syst Pharm . 2001; 58: 2381-99. [PubMed 11794954]

422. Claudius C, Garvey LH, Viby-Mogensen J. The undesirable effects of neuromuscular blocking drugs. Anaesthesia . 2009; 64 Suppl 1:10-21. [PubMed 19222427]

423. Murray MJ, DeBlock H, Erstad B et al. Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient. Crit Care Med . 2016; 44:2079-2103. [PubMed 27755068]

424. Hampton JP. Rapid-sequence intubation and the role of the emergency department pharmacist. Am J Health Syst Pharm . 2011; 68:1320-30. [PubMed 21719592]

425. Institute for Safe Medication Practices. 2018-2019 Targeted medication safety best practices for hospitals. Horsham, PA; 2017 Dec. From ISMP website [Web]