Induction of skeletal muscle paralysis and facilitation of intubation after induction of anesthesia in surgical procedures.
Facilitation of compliance during mechanical ventilation.
Action
Prevents neuromuscular transmission by blocking the effect of acetylcholine at the myoneural junction. Has no analgesic or anxiolytic properties
Therapeutic Effect(s):
Skeletal muscle paralysis.
Pharmacokinetics
Absorption: Following IV administration, absorption is essentially complete.
Distribution: Rapidly distributes into extracellular space.
Metabolism and Excretion: Mostly metabolized and eliminated by the liver.
Half-life: Infants 3–12 mo: 0.8–1.8 hr; Children 1–3 yr: 0.4–1.8 hr; Children 3–8 yr: 0.5–1.1 hr; Adults: 1.4–2.4 hr (↑ to 4.3 hr in hepatic impairment and 2.4 hr in renal impairment)
TIME/ACTION PROFILE
ROUTE
ONSET
PEAK
DURATION
IV
1 min
0.5–1 min (peds) 1–3.7 min (adults)
26–40 min (peds) 31 min (adults)*
*Following 0.6 mg/kg dose in adult patients.
Contraindication/Precautions
Contraindicated in:
Hypersensitivity
Use Cautiously in:
Dehydration or electrolyte abnormalities (should be corrected)
Fractures or muscle spasm
Hyperthermia (↑ duration/intensity of paralysis)
Significant hepatic impairment
Shock
Extensive burns (may be more resistant to effects)
Low plasma pseudocholinesterase levels (may be seen in association with anemia, dehydration, cholinesterase inhibitors/insecticides, severe liver disease, pregnancy, or hereditary predisposition)
Obese patients
OB: Lactation: Safety not established (use only if benefit outweighs potential risk to fetus)
Pedi: Children <3 mo (safety and effectiveness not established)
Exercise Extreme Caution in:
Neuromuscular diseases such as myasthenia gravis (small test dose may be used to assess response).
Adverse Reactions/Side Effects
Resp: bronchospasm
Derm: rash
Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS
* CAPITALS indicate life-threatening. Underline indicate most frequent.
Interactions
Drug-Drug
Intensity and duration of paralysis may be prolonged by pretreatment with succinylcholine, general anesthesia (inhalation), aminoglycosides, vancomycin, tetracyclines, polymyxin B, colistin, clindamycin, lidocaine, and other local anesthetics, lithium, quinidine, procainamide, beta-adrenergic blocking agents, potassium-losing diuretics, or magnesium.
Higher infusion rates may be required and duration of action may be shortened in patients receiving long-term carbamazepine or phenytoin.
May be associated with QTc interval prolongation when administered with general anesthesia.
Assess respiratory status continuously throughout therapy with neuromuscular blocking agents. These medications should be used only to facilitate intubation or in patients already intubated.
Neuromuscular response should be monitored with a peripheral nerve stimulator intraoperatively. Paralysis is initially selective and usually occurs sequentially in the following muscles: levator muscles of eyelids, muscles of mastication, limb muscles, abdominal muscles, muscles of the glottis, intercostal muscles, and the diaphragm. Recovery of muscle function usually occurs in reverse order.
Monitor ECG, heart rate, and BP throughout administration.
Observe the patient for residual muscle weakness and respiratory distress during the recovery period.
Monitor infusion site frequently. If signs of tissue irritation or extravasation occur, discontinue and restart in another vein.
Toxicity Overdose: If overdose occurs, use peripheral nerve stimulator to determine the degree of neuromuscular blockade. Maintain airway patency and ventilation until recovery of normal respirations occurs.
Administration of anticholinesterase agents (neostigmine, pyridostigmine) may be used to antagonize the action of neuromuscular blocking agents once the patient has demonstrated some spontaneous recovery from neuromuscular block. Atropine is usually administered prior to or concurrently with anticholinesterase agents to counteract the muscarinic effects.
Administration of fluids and vasopressors may be necessary to treat severe hypotension or shock.
High Alert: Unplanned administration of a neuromuscular blocking agent instead of administration of the intended medication or administration of a neuromuscular blocking agent in the absence of ventilatory support has resulted in serious harm and death. Confusing similarities in packaging and insufficiently controlled access to these medications are often implicated in these medication errors.
Dose is titrated to patient response.
Neuromuscular blocking agents have no effect on consciousness or pain threshold. Adequate anesthesia/analgesia should always be used when neuromuscular blocking agents are used as an adjunct to surgical procedures or when painful procedures are performed. Benzodiazepines and/or analgesics should be administered concurrently when prolonged neuromuscular blocker therapy is used for ventilator patients, because patient is awake and able to feel all sensations.
If eyes remain open throughout prolonged administration, protect corneas with artificial tears.
Store rocuronium in refrigerator.
IV Administration
IV Push: Administer undiluted.
Rate: Titrate according to patient response.
Continuous Infusion: Diluent: 0.9% NaCl, sterile water for injection, D5W, LR injection, and D5/0.9% NaCl for infusion. Solution is stable for 24 hr at room temperature. Concentration: 0.5–1 mg/mL.
Rate: Infusion rates of 0.004–0.016 mg/kg/min have been used. Rate of infusion should be titrated according to patient's twitch response as monitored with a peripheral nerve stimulator.
Y-Site Compatibility
acyclovir
alemtuzumab
alfentanil
amikacin
aminocaproic acid
aminophylline
amiodarone
ampicillin
ampicillin/sulbactam
anidulafungin
argatroban
azithromycin
aztreonam
bivalirudin
bleomycin
bumetanide
buprenorphine
butorphanol
calcium chloride
calcium gluconate
carboplatin
carmustine
caspofungin
cefepime
cefotaxime
cefotetan
cefoxitin
ceftazidime
ceftriaxone
cefuroxime
chlorpromazine
ciprofloxacin
clindamycin
cyclophosphamide
cytarabine
daptomycin
dexmedetomidine
dexrazoxane
digoxin
diltiazem
diphenhydramine
dobutamine
docetaxel
dolasetron
dopamine
doxycycline
droperidol
enalaprilat
ephedrine
epinephrine
epirubicin
eptifibatide
ertapenem
esmolol
etoposide
etoposide phosphate
fenoldopam
fentanyl
fluconazole
fludarabine
foscarnet
fosphenytoin
ganciclovir
gemcitabine
gentamicin
granisetron
haloperidol
heparin
hydrocortisone sodium phosphate
hydromorphone
idarubicin
ifosfamide
imipenem/cilastatin
irinotecan
isoproterenol
labetalol
levofloxacin
levorphanol
lidocaine
linezolid
magnesium hydroxide
mannitol
mechlorethamine
meperidine
meropenem
methotrexate
metoclopramide
metoprolol
metronidazole
midazolam
milrinone
mitoxantrone
morphine
moxifloxacin
mycophenolate
nalbuphine
naloxone
nesiritide
nicardipine
nitroglycerin
nitroprusside
octreotide
ondansetron
oxaliplatin
palonosetron
pamidronate
pemetrexed
pentamidine
pentobarbital
phenobarbital
phenylephrine
potassium acetate
potassium chloride
procainamide
prochlorperazine
promethazine
propranolol
quinupristin/dalfopristin
ranitidine
remifentanil
sodium acetate
sodium bicarbonate
sodium phosphates
sufentanil
tacrolimus
teniposide
theophylline
thiotepa
tigecycline
tirofiban
tobramycin
vasopressin
verapamil
vincristine
voriconazole
zidovudine
zoledronic acid
Y-Site Incompatibility
amphotericin B colloidal
amphotericin B lipid complex
azathioprine
diazepam
furosemide
hydrocortisone sodium succinate
insulin
ketorolac
lorazepam
methohexital
methoprednisolone
micafungin
pantoprazole
phenytoin
piperacillin/tazobactam
potassium phosphates
thiopental
Patient/Family Teaching
Explain all procedures to patient receiving neuromuscular blocker therapy without general anesthesia, because consciousness is not affected by neuromuscular blocking agents alone.
Reassure patient that communication abilities will return as the medication wears off.
Evaluation/Desired Outcomes
Adequate suppression of the twitch response when tested with peripheral nerve stimulation and subsequent muscle paralysis.
Improved compliance during mechanical ventilation.
Diagnosis of myasthenia gravis.
rocuronium is a sample topic from the Davis's Drug Guide.
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