Adult Dosing
Tracheal intubation
- Start 0.6 mg/kg IV, intubation is attained within 3 minutes. This dose may provide 31 minutes of clinical relaxation under opioid/nitrous oxide/oxygen anesthesia
- Alt: A lower dose of 0.45 mg/kg may be used, intubation is attained within 4 minutes, 25% of recovery is attained in 12-15 minutes
- Max: 0.9-1.2 mg/kg can be administered under opioid/nitrous oxide/oxygen anesthesia without adverse effects to the cardiovascular system
Rapid sequence intubation
- 0.6 mg-1.2 mg/kg IV, intubation is attained in less than 2 minutes
Maintenance dose
- 0.1, 0.15, and 0.2 mg/kg IV, administered at 25% recovery, provide a median of 12, 17, and 24 minutes of clinical duration under opioid/nitrous oxide/oxygen anesthesia
- Dosing should be guided based on the clinical duration following initial dose or prior maintenance dose and should not be administered until recovery of neuromuscular function is evident
Use by continuous infusion
- Initial rate of 10-12 mcg/kg/min IV; start only after early evidence of spontaneous recovery from an intubating dose
- After achieving the desired response, administer at infusion rates 4-16 mcg/kg/minute IV; adjust the infusion rate as per the patient's twitch response monitored using a peripheral nerve stimulator
- In the presence of steady-state concentrations of inhalation anesthetics such as enflurane or isoflurane, consider reducing the rate of infusion by 30-50% at 45-60 minutes after the intubating dose
Note:
- For obese patients, use the patient's actual body weight
Pediatric Dosing
- Rocuronium is not recommended for rapid sequence intubation in pediatric patients
Neuromuscular blockade induction
rocuronium (generic)
- 3 months-14 yrs
- Recommended initial intubation dose is 0.6 mg/kg IV. In the presence of halothane, administration of 0.6 mg/kg provided excellent to good intubating conditions within 60 seconds
Zemuron
- Recommended initial intubation dose is 0.6 mg/kg IV. In the presence of halothane, administration of 0.6 mg/kg provided excellent to good intubating conditions within 60 seconds
- Alt: A lower dose of 0.45 mg/kg may be used
- Doses 0.45 mg/kg and 0.6 mg/kg produce excellent to good intubating conditions within 75 seconds under sevoflurane
Note:
- Time to maximum block for an intubating dose is shortest in infants and longest in neonates; whereas clinical relaxation is shortest in children (>2-11 yrs) and longest infants
Neuromuscular blockade maintenance
rocuronium (generic)
- When halothane is used for general anesthesia, doses of 0.075-0.125 mg/kg IV provide clinical relaxation for 7-10 min
- Alt: Continuous infusion at a rate of 12 mcg/kg/min
Zemuron
- At reappearance of T3 0.15 mg/kg IV bolus dose can be administered under isoflurane/nitrous oxide for all pediatric age groups
- At reappearance of T2 dose of 7-10 mcg/kg/min IV can be administered under isoflurane/nitrous oxide with lowest for neonates and highest for children
- When halothane is used for general anesthesia, doses of 0.075-0.125 mg/kg IV provide clinical relaxation for 7-10 min
- Alt: Continuous infusion at a rate of 12 mcg/kg/min
- Rocuronium should be administered in carefully adjusted dosages by or under the supervision of experienced clinicians who are well trained in its use and where facilities for intubation, mechanical ventilation, oxygen therapy, and reversal agents are immediately available
- Doses should be individualized and a peripheral nerve stimulator should be used to monitor drug effect, need for additional doses, adequacy of spontaneous recovery or antagonism, and to decrease the complications of overdosage when additional doses are administered
- Severe anaphylactic reactions, sometimes fatal or life-threatening reactions, have occurred with rocuronium. Keep appropriate emergency treatment readily available in case such reactions occur
- Use cautiously in patients who have had anaphylactic reactions to other neuromuscular blocking agents in the past, as there have been reports of cross-reactivity among drugs of this class
- Rocuronium administration must be accompanied by adequate anesthesia or sedation
- It is recommended to extubate only after the patient has recovered sufficiently from neuromuscular block in order to prevent complications resulting from residual paralysis
- Monitor neuromuscular transmission continuously with the help of a nerve stimulator during administration and recovery. Do not give additional doses of any neuromuscular blocking agent until there is a definite response (one twitch of the train-of-four) to nerve stimulation
- Tolerance may develop during chronic administration in the intensive care unit
- Incidence of prolonged paralysis and/or skeletal muscle weakness has been reported during initial attempts to wean from the ventilator in patients who have chronically received neuromuscular blocking drugs in the ICU
- Long-term use of rocuronium alone or in combination with corticosteroid therapy in the ICU may cause myopathy
- Drugs used in anesthetic practice may trigger a potentially fatal hypermetabolism of skeletal muscle known as malignant hyperthermia
- Patients with an increased circulatory delayed time (e.g., cardiovascular disease, elderly, edematous states) should not increase the dose as it may cause delayed onset of action
- In pediatric patients, concomitant use of rocuronium with general anesthetic agents can prolong the QTc interval
- A lower initial dose should be considered in cachectic or debilitated patients, patients with neuromuscular diseases and with carcinomatosis
- Some inhalation anesthetics, especially enflurane and isoflurane, magnesium salts, antibiotics, local anesthetics, procainamide, lithium, and quinidine have been shown to increase the duration of neuromuscular block and decrease infusion requirements of neuromuscular blocking agents
- Resistance to nondepolarizing muscle relaxants may occasionally develop in patients with cerebral palsy, patients chronically receiving anticonvulsant agents such as carbamazepine or phenytoin, or with chronic exposure to nondepolarizing agents
- Severe abnormalities in acid-base and/or electrolytes may potentiate or cause resistance to the neuromuscular blocking action of rocuronium
- Do not mix alkaline solutions such as barbiturate solutions with rocuronium (which has an acidic pH) in the same syringe or administer simultaneously during IV infusion through the same needle
- Patients with myasthenia gravis or the myasthenic (Eaton-Lambert) syndrome should be carefully monitored while on treatment as even small doses of neuromuscular blocking agents may have profound effects in such patients
- If extravasation with signs or symptoms of local irritation occurs, terminate the injection or infusion immediately and restart in another vein
- Rocuronium is not recommended for rapid sequence intubation in children
Cautions: Use cautiously in
- Hepatic impairment
- Pulmonary hypertension
- Valvular heart disease
- Pulmonary disease
- Dehydration
- Severe hypothermia
Pregnancy Category:C
Breastfeeding: Safety unknown. Manufacturer advises caution.
