Rocuronium bromide is an aminosteroid nondepolarizing neuromuscular blocking agent.1, 420
Rocuronium bromide is used as an adjunct to general anesthesia to facilitate both rapid sequence and routine tracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation.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
In US clinical studies, a total of 1137 patients (176 pediatric, 140 geriatric, 55 obstetric, and 766 adult patients) received rocuronium; 90% of patients were American Society of Anesthesiologists (ASA) physical status I or II, 9% were ASA III, and 10 patients were ASA IV (these patients were undergoing coronary artery bypass grafting [CABG] or valvular surgery).1 In European clinical studies, a total of 1394 patients received rocuronium, including 52 pediatric patients, 128 geriatric patients, and 1214 adults.1
Intubation using rocuronium bromide 0.6-0.85 mg/kg was evaluated in 11 clinical studies enrolling a total of 203 adults.1 In these studies, excellent to good intubating conditions were generally achieved within 2 minutes, and maximum block occurred within 3 minutes in most patients.1 Clinical relaxation was provided for a median of 33 minutes under opioid/nitrous oxide/oxygen anesthesia.1 Larger dosages (0.9 and 1.2 mg/kg) were evaluated in 2 studies enrolling 19 and 16 patients under opioid/nitrous oxide/oxygen anesthesia; in these studies, rocuronium provided 58 and 67 minutes of clinical relaxation, respectively.1
In a study of 10 patients with clinically significant cardiovascular disease undergoing CABG, rocuronium was administered at an initial dosage of 0.6 mg/kg, and neuromuscular blockade was maintained during surgery with bolus maintenance doses of 0.3 mg/kg.1 Following induction, a continuous infusion of 8 mcg/kg/min rocuronium produced sufficient relaxation to support mechanical ventilation for 6-12 hours in the surgical intensive care unit while patients were recovering from surgery.1
In most clinical studies, patients were dosed according to actual body weight (ABW), and no substantial differences in rocuronium pharmacokinetics were observed in patients who were 30% or more above their ideal body weight (IBW).1 In one clinical study, obese patients received rocuronium 0.6 mg/kg according to ABW (12 patients) or IBW (11 patients).1 Obese patients who were dosed according to IBW had a longer time to maximum blockade and a shorter median clinical duration of blockade; these patients did not achieve intubating conditions comparable to those achieved in patients who were dosed according to ABW.1 In light of these findings, the manufacturer recommends dosing rocuronium according to ABW.1 Another randomized controlled trial of 51 obese patients undergoing gastric banding or gastric bypass surgery found that rocuronium dosed according to IBW allowed for a shorter duration of action without significantly prolonging the time to onset or compromising tracheal intubation conditions compared to rocuronium dosed according to corrected body weight.112
Rocuronium 0.6 mg/kg was evaluated in 6 clinical studies enrolling 55 geriatric patients (65-80 years of age); at this dose, rocuronium provided excellent to good intubating conditions after a median of 2.3 minutes.1 Recovery times were not prolonged in geriatric patients compared to other adult patients.1
Rocuronium has been evaluated for intubation in 2 studies enrolling 326 pediatric patients who underwent sevoflurane induction and isoflurane/nitrous oxide maintenance anesthesia.1 Rocuronium was administered at a dose of 0.45, 0.6, or 1 mg/kg.1 In all age groups, a dose of 0.6 mg/kg produced maximum blockade in about 1 minute.1 Median time to reappearance of T3 was shortest in children (36.7 minutes) and longest in infants (59.8 minutes).1 For pediatric patients >3 months of age, the time to recovery was shorter after stopping infusion maintenance when compared with bolus maintenance.1
Rocuronium 0.6 or 0.8 mg/kg has been evaluated for intubation in 3 studies enrolling 75 pediatric patients who were administered halothane (no longer available in the US) and nitrous oxide in oxygen (28 patients: 3-12 months of age and 47 patients: 1-12 years of age).1 Doses of 0.6 mg/kg provided a median time to maximum blockade of 1 minute; the median duration of clinical relaxation was 41 minutes in patients 3-12 months of age and 26 minutes in patients 1-12 years of age.1
Use of rocuronium for rapid sequence intubation in adults was assessed in 6 clinical studies where anesthesia was induced with either thiopental (no longer available in the US) or propofol in combination with either fentanyl or alfentanil.1 Most patients also received premedication (e.g., midazolam, temazepam).1 Intubation was attempted within 60-90 seconds of administration of rocuronium 0.6 mg/kg or succinylcholine 1-1.5 mg/kg; excellent or good intubating conditions were achieved in 99% of patients who received rocuronium and 98% of patients administered succinylcholine.1
A Cochrane review of 50 trials enrolling 4151 patients compared rocuronium (≥0.6 mg/kg) to succinylcholine (≥1 mg/kg) for rapid sequence induction intubation in all age groups and settings.110 In this analysis, succinylcholine was superior to rocuronium for achieving excellent intubating conditions and clinically acceptable intubation conditions.110 Most of the included studies used a rocuronium dose of 0.6 mg/kg; however, higher doses (e.g., 1 mg/kg) are typically favored in clinical practice.110 Subgroup analyses found no difference in intubation conditions between succinylcholine and rocuronium when rocuronium was dosed at 0.9-1 mg/kg or 1.2 mg/kg.110 A subsequent randomized controlled trial in 1248 adults requiring out-of-hospital tracheal intubation compared rocuronium 1.2 mg/kg with succinylcholine 1 mg/kg for rapid sequence intubation with a primary endpoint of intubation success on first attempt.111 Successful intubation on first attempt was achieved in 74.6% of patients receiving rocuronium and 79.4% of patients receiving succinylcholine; based on a noninferiority margin of 7%, rocuronium failed to demonstrate noninferiority to succinylcholine for this outcome.111
Neuromuscular blocking agents are classified as depolarizing or nondepolarizing based on their mechanism of action.420, 421, 424 Succinylcholine is the only currently available depolarizing neuromuscular blocking agent.424 Nondepolarizing neuromuscular blocking agents include atracurium, cisatracurium, rocuronium, and vecuronium; these drugs are further characterized based on their structure as a benzylisoquinolinium (atracurium, cisatracurium) or aminosteroid (rocuronium, vecuronium) compound.424 The choice of a specific neuromuscular blocking agent should be individualized based on factors such as the clinical setting (surgical or ICU), duration of procedure, anesthetic technique, patient condition, and adverse effects and pharmacokinetic profile (onset and duration) of the drug.420, 421, 423
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.420, 421, 424 For critically ill adult patients who require rapid sequence intubation, the Society of Critical Care Medicine (SCCM) suggests that either rocuronium or succinylcholine may be used when there are no known contraindications to succinylcholine.426
Dispensing and Administration Precautions
Rocuronium bromide is administered IV only.1
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 The rate of spontaneous neuromuscular recovery following discontinuance of the infusion is likely to be comparable to the rate of recovery following administration of comparable total doses administered via repetitive bolus injections.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
If rocuronium is administered via the same infusion line as other drugs, ensure that the infusion line is adequately flushed between administration of rocuronium and administration of drugs for which compatibility with rocuronium has not been established.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
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. 249Because 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. 249For additional information on S4S (including updates that may be available), see [Web].
Patient Population | Concentration Standards | Dosing Units |
|---|---|---|
Adultsa | 10 mg/mL | mcg/kg/minb |
Pediatric patients (<50 kg) | 10 mg/mL | mcg/kg/minb |
aParalytics are recommended to be administered as straight drug. This provides consistency between operating room and the ICU, and eliminates potential compounding errors.
Dosage of rocuronium bromide is expressed in terms of the salt.1 The dosage 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 muscle relaxation, determine the need for additional doses, determine the adequacy of spontaneous recovery or antagonism, and minimize the complications of overdosage if additional doses are administered.1, 113, 114, 423
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
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 a median time of 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 a median time of 1.3 minutes (range: 0.8 to 6.2 minutes), complete intubation within 2 minutes, maximum blockade in less than 4 minutes, and clinically sufficient blockade for about 22 minutes (range: 12 to 31 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
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) can be expected to provide clinically sufficient neuromuscular blockade for a median of 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/min 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/min 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
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 pediatric patients 3-12 months of age) or 26 minutes (in pediatric patients 1-12 years of age).1 When used concomitantly with sevoflurane (induction), 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/min per upon return of T1 to 10% (i.e., one twitch present in a train-of-four).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/min at the reappearance of T2.1
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
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
Geriatric patients may exhibit a slightly prolonged median clinical duration of blockade (46, 62, and 94 minutes with rocuronium doses of 0.6, 0.9, and 1.2 mg/kg, respectively, under opioid/nitrous oxide/oxygen anesthesia).1 No differences in duration of neuromuscular blockade following maintenance doses of rocuronium were observed between geriatric patients and younger patients, but increased sensitivity of some older individuals cannot be ruled out.1
Patients with Reduced Plasma Cholinesterase Activity
Because metabolism of rocuronium does not depend on plasma cholinesterase, dosage adjustment is not necessary in patients with reduced activity of this enzyme.1
Patients with Prolonged Circulation Time
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
In obese patients, the manufacturer states that the initial dose of rocuronium 0.6 mg/kg should be based on actual body weight (ABW).1 Some experts suggest that clinicians use ideal body weight (IBW) or adjusted body weight, rather than ABW, to dose neuromuscular blocking agents in critically ill obese patients.423 The weight used (ideal, adjusted, or actual) should remain consistent throughout therapy.423
Appropriate Administration and Monitoring
An experienced clinician familiar with rocuronium's actions and possible complications should supervise administration of the drug.1 Administer rocuronium in carefully adjusted dosages; do not administer the drug unless facilities for intubation, mechanical ventilation, oxygen therapy, and an antagonist are immediately available.1
Clinicians should use a peripheral nerve stimulator to monitor drug effect, assess the need for additional doses, assess adequacy of spontaneous recovery or antagonism, and decrease the complications of overdosage if additional doses are administered.1
Severe anaphylactic reactions have been reported with all neuromuscular blocking agents, including rocuronium; such reactions were life-threatening or fatal in some cases.1 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
Risk of Death Due to Medication Errors
Rocuronium administration results in paralysis, which may lead to respiratory arrest and death; this may be more likely to occur if it is administered to a patient for whom it was not intended.1 Confirm that the intended product has been properly selected, and avoid confusion with other injectable solutions that are present in critical care and other clinical settings.1 If another healthcare provider is administering the product, ensure that the intended dosage is clearly labeled and communicated.1
Because rocuronium has no known effect on consciousness, pain threshold, or cerebration, its administration must be accompanied by adequate anesthesia or sedation.1
Residual neuromuscular blockade may occur after cessation of neuromuscular blocking drugs; the risk of residual neuromuscular blockade may be increased in geriatric patients.1 Consider factors such as drug interactions and patient condition when assessing the risk for residual neuromuscular blockade.1 In order to prevent complications from residual paralysis, consider use of a reversal agent and only extubate patients when adequate recovery of neuromuscular function is assured.1
Long-term Use in an Intensive Care Setting
Prolonged paralysis and/or muscle weakness have been reported after long-term use of neuromuscular blocking agents to support mechanical ventilation in the intensive care unit (ICU).1 Myopathy has also been reported after long-term use of neuromuscular blocking agents in the ICU alone or in combination with corticosteroid therapy.1 Tolerance to rocuronium may develop during chronic administration in the ICU.1
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 In patients receiving neuromuscular blocking agents and corticosteroids concomitantly, limit the period of use of the neuromuscular blocking agent as much as possible; only use a neuromuscular blocking agent when advantages of the drug outweigh the risks.1
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
Patients with conditions that prolong circulation time (e.g., cardiovascular disease, advanced age) may experience a delay in the onset time of rocuronium.1
Prolongation of the QT interval has been reported in pediatric patients receiving rocuronium and general anesthetics concomitantly.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, neuromuscular diseases, 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, cerebral palsy, and long-term use of carbamazepine, phenytoin, or neuromuscular blocking agents.1 An increase in rocuronium dosage may be required.1
Increased or decreased neuromuscular blockade is possible in patients with electrolyte disturbances or acid/base abnormalities receiving rocuronium.1
Incompatibility with Alkaline Solutions
Rocuronium bromide has an acidic pH and should not be mixed with alkaline solutions (e.g., barbiturate solutions) in the same syringe or infused simultaneously with such solutions through the same needle.1
Increased Pulmonary Vascular Resistance
Rocuronium may increase pulmonary vascular resistance; caution is advised in patients with pulmonary hypertension or valvular heart disease.1
Use in Patients with Myasthenia
Patients with myasthenia gravis or myasthenic (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
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
There are no adequate and well-controlled studies of rocuronium in pregnant women.1 In animal studies, teratogenicity was not observed.1 High-dose rocuronium was associated with acute symptoms of respiratory dysfunction in pregnant, conscious, non-ventilated rabbits and rats.1 The incidence of late embryonic death was increased in rats, most likely due to oxygen deficiency; this finding is not likely to be relevant for humans, since immediate mechanical ventilation of the intubated patient will prevent embryofetal hypoxia.1 Use rocuronium during pregnancy only if the potential benefit justifies the potential risk to the fetus.1
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
No information is available regarding the use of rocuronium in lactating patients.1
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 (QTc) interval in pediatric patients.1
The manufacturer states that rocuronium is not recommended for rapid sequence intubation in pediatric patients.1
Rocuronium has been evaluated in geriatric patients ≥65 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
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 If used for rapid sequence induction in patients with ascites, an increased initial dosage may be necessary to ensure complete block; duration will be prolonged in these cases.1
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, but substantial individual variability exists.1 Onset time is not affected by renal impairment.1
The most common adverse effects of rocuronium observed in 2% of patients in clinical studies were transient hypotension and hypertension.1
Resistance to the neuromuscular blocking effects of rocuronium (e.g., diminished magnitude of the blockade, shortened clinical duration) has been observed in patients receiving long-term phenytoin or carbamazepine therapy.1 Higher rocuronium infusion rates may be necessary in such patients.1
The possibility that some anti-infective agents (e.g., aminoglycosides, bacitracin, colistin, 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
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
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
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
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
There are no controlled studies documenting the use of rocuronium before or after other nondepolarizing neuromuscular blocking agents.1 Interactions have been observed when other nondepolarizing neuromuscular blocking agents have been administered in succession.1
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 has no apparent effect on the duration of neuromuscular blockade induced by rocuronium or on subsequent recovery of neuromuscular function.1
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
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
Rocuronium bromide is a nondepolarizing neuromuscular blocking agent.1 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
Following IV administration of rocuronium 0.45 or 0.6 mg/kg in adults undergoing opioid/nitrous oxide/oxygen anesthesia, neuromuscular blockade is clinically sufficient in a median time of 1.3 (range: 0.8-6.2) or 1 (range: 0.4-6) minute, respectively, and maximal in 3 (range: 1.3-8.2) or 1.8 (range: 0.6-13) minutes, respectively.1 Clinically sufficient neuromuscular blockade persists for about 22 (range: 12-31) or 31 (range: 15-85) minutes, respectively.1 Higher doses of 0.9 or 1.2 mg/kg produce clinically sufficient neuromuscular blockade in about 1.1 (range: 0.3-3.8) or 0.7 (range: 0.4-1.7) minutes, respectively, and maximal blockade in 1.4 (range: 0.8-6.2) or 1 (range: 0.6-4.7) minutes, respectively.1 Clinically sufficient neuromuscular blockade persists for about 58 (range: 27-111) or 67 (range: 38-160) minutes for these doses, respectively.1 Following maintenance doses of 0.1, 0.15, or 0.2 mg/kg in adults receiving opioid/nitrous oxide/oxygen anesthesia, clinically sufficient neuromuscular blockade persists for about 12 (range: 2-31), 17 (range: 6-50), or 24 (range: 7-69) minutes, respectively.1 The median time necessary for 25-75% recovery from neuromuscular blockade in adults is about 13 minutes.1
Maximum neuromuscular blockade generally occurs within 1 minute in pediatric patients.1 In infants 3 months to 1 year of age undergoing halothane anesthesia, the duration of clinically sufficient neuromuscular blockade with rocuronium 0.6 mg/kg was 41 (range: 24-68) minutes.1 In pediatric patients 1-12 years of age undergoing halothane anesthesia, the duration of clinically sufficient neuromuscular blockade with rocuronium 0.6 mg/kg was 26 (range: 17-39) minutes.1 Following maintenance doses of 0.075-0.125 mg/kg in pediatric patients, clinically sufficient neuromuscular blockade persists for 7-10 minutes.1
Rocuronium is approximately 30% protein-bound.1 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 The terminal half-life of rocuronium is 1.4-1.5 hours in adults undergoing opioid/nitrous oxide/oxygen anesthesia, 2.4 hours in adults undergoing isoflurane anesthesia, 0.8-1.3 hours in pediatric patients (3 months to <8 years of age) undergoing halothane anesthesia, and 0.7-1.1 hours in pediatric patients (birth to ≤17 years of age) receiving induction anesthesia with sevoflurane and maintenance anesthesia with isoflurane/nitrous oxide.1 Terminal half-life is prolonged in adults with hepatic dysfunction (4.3 hours in patients undergoing isoflurane anesthesia).1
Rocuronium exhibits transient increases in heart rate and minimal histamine-releasing activity at usual therapeutic doses.1
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.
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
Routes | Dosage Forms | Strengths | Brand Names | Manufacturer |
|---|---|---|---|---|
Parenteral | Injection, for IV use only | 10 mg/mL* |
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name
AHFS® Drug Information. © Copyright, 1959-2025, Selected Revisions October 10, 2025. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, MD 20814.
1. Hospira. Rocuronium bromide injection prescribing information. Lake Forest, IL; 2023 Jun.
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]
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]
111. Guihard B, Chollet-Xémard C, Lakhnati P, Vivien B, Broche C, Savary D, Ricard-Hibon A, Marianne Dit Cassou PJ, Adnet F, Wiel E, Deutsch J, Tissier C, Loeb T, Bounes V, Rousseau E, Jabre P, Huiart L, Ferdynus C, Combes X. Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation: A Randomized Clinical Trial. JAMA. 2019 Dec 17;322(23):2303-2312.
112. Meyhoff CS, Lund J, Jenstrup MT, Claudius C, Sørensen AM, Viby-Mogensen J, Rasmussen LS. Should dosing of rocuronium in obese patients be based on ideal or corrected body weight? Anesth Analg. 2009 Sep;109(3):787-92.
113. Thilen SR, Weigel WA, Todd MM, Dutton RP, Lien CA, Grant SA, Szokol JW, Eriksson LI, Yaster M, Grant MD, Agarkar M, Marbella AM, Blanck JF, Domino KB. 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology. 2023 Jan 1;138(1):13-41.
114. Smith HAB, Besunder JB, Betters KA, Johnson PN, Srinivasan V, Stormorken A, Farrington E, Golianu B, Godshall AJ, Acinelli L, Almgren C, Bailey CH, Boyd JM, Cisco MJ, Damian M, deAlmeida ML, Fehr J, Fenton KE, Gilliland F, Grant MJC, Howell J, Ruggles CA, Simone S, Su F, Sullivan JE, Tegtmeyer K, Traube C, Williams S, Berkenbosch JW. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatr Crit Care Med. 2022 Feb 1;23(2):e74-e110.
249. ASHP. Standardize 4 Safety: pediatric continuous infusion standard. Updated 2025 Jun. From ASHP website. Updates may be available at ASHP website. [Web]
250. ASHP. Standardize 4 Safety: adult continuous infusion standard. Updated 2025 Jun. From ASHP website. Updates may be available at ASHP 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]
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. 2024-2025 Targeted medication safety best practices for hospitals. 2024 Feb. From ISMP website [Web]
426. Acquisto NM, Mosier JM, Bittner EA, Patanwala AE, Hirsch KG, Hargwood P, Oropello JM, Bodkin RP, Groth CM, Kaucher KA, Slampak-Cindric AA, Manno EM, Mayer SA, Peterson LN, Fulmer J, Galton C, Bleck TP, Chase K, Heffner AC, Gunnerson KJ, Boling B, Murray MJ. Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient. Crit Care Med. 2023 Oct 1;51(10):1411-1430.
427. Institute for Safe Medication Practices (ISMP). ISMP list of high-alert medications in acute care settings. ISMP; 2024.