Rocuronium Bromide

Brand names Zemuron, generic

Medication error ISMP high-alert medication that has an increased risk of causing significant patient harm potential if it is used in error.(1) Look-alike, sound-alike drug names USP reports that rocuronium has been confused with Romazicon and vecuronium; no patient harm resulted. USP also reports that Zemuron has been confused with vecuronium; patient death resulted.(2)

Contraindications Contraindications: Hypersensitivity to rocuronium or any of its components.(3) and warnings In one study, 69% of patients with confirmed rocuronium allergy demonstrated cross- sensitivity to vecuronium.(4) Warnings: Use carefully under the supervision of experienced clinicians; personnel should be skilled in airway management, resuscitation, and respiratory support. Intubation and ventilatory support equipment, including oxygen therapy, should be readily available. Reversal agents should be readily available when giving rocuronium.(3)

Infusion-related Hypersensitivity reactions, hypotension, arrhythmias, bronchospasm, and severe ana- cautions phylaxis (life-threatening in some cases) have been reported but appear to be rare.(3)

Dosage Respiratory function must be supported during use of this agent. Concurrent administration of a sedative is also necessary. Monitoring of neuromuscular transmission with a peripheral nerve stimulator is recommended during continuous infusion or with repeated dosing.(3,5) Dosing adjustment for obesity: The manufacturer recommends that the dose (0.6 mg/kg) should be based on actual body weight, not ideal or body mass.(3) However, two studies in morbidly obese adults found that doses of 1.2 mg/kg(6) and 0.6 mg/kg(7) based on ideal body weight provided clinically acceptable intubating conditions for . Authors of an opinion-based review on dosing adjustments of agents in mor- bidly obese patients recommend rocuronium be dosed using ideal body weight to avoid prolonged duration of paralysis.(27) Pediatric consensus guidelines also recommend using ideal body weight for rocuronium dosing.(28) When administered with inhalational , such as , , or sevo- flurane, the dose of rocuronium should be reduced by 20% to 50%.(8,9) (See individual dosing sections.) Induction and maintenance of neuromuscular blockade Neonates: 0.5–1.2 mg/kg for nonemergent intubation.(10,11) Infants: 0.3–0.6 mg/kg repeated q 20–30 min PRN to maintain pharmacological paralysis.(3,11-14,28) AAP recommends 1 mg/kg for intubation.(15) May follow a bolus dose with a continuous infusion of 0.3–0.8 mg/kg/hr (5–13 mcg/kg/min).(3,9,16,28) Maintenance doses during halothane are 0.075–0.125 mg/kg, and during /isoflurane anesthesia are 0.15 mg/kg PRN.(3) Children: 0.4–0.8 mg/kg repeated q 20–30 min PRN to maintain pharmacological paralysis.(3,28,12-14,17) May follow a bolus dose with a continuous infusion of 0.3–0.8 mg/kg/hr (5–13 mcg/kg/min).(3,9,16,28) (See the Comments section.) Maintenance doses during halothane anesthesia are 0.075–0.125 mg/kg, and during sevoflurane/isoflurane anesthesia are 0.15 mg/kg.(3)

Dosage adjustment An increased initial dosage may be required for complete neuromuscular blockade in in organ dysfunction patients with hepatic impairment.(3) Duration of neuromuscular blockade may be prolonged in patients with hepatic impairment.(3) No dosage adjustment required in those with renal impairment.(3) In children with renal failure who were older than 1 year of age, a single bolus dose did not cause prolonged neuromuscular blockade but was associated with a slower onset of action than that noted in healthy children.(18)  768 Rocuronium Bromide

Maximum dosage Bolus doses as high as 2 mg/kg,(13) and continuous infusions up to 2.2 mg/kg/hr (37 mcg/kg/min)(16) have been reported.

Additives None

Suitable diluents D5W, D5NS, NS, LR(3,19)

Maximum 10 mg/mL for IV push; 5 mg/mL for infusion.(3) concentration

Preparation and Parenteral products should be visually inspected for particulate matter and discoloration delivery before use. Refer to appropriate references for more information on compatibility with other drugs and solutions, compatibility following Y-site delivery, and suggested storage and extended stability.(19) Rocuronium is an acidic solution; do not administer with alkaline solutions.(3)

IV push 10 mg/mL(3)

Intermittent infusion Not administered by this method

Continuous infusion The manufacturer provides information for continuous infusion with a solution of 0.5, 1, and 5 mg/mL.(3)

Other routes of Not recommended by manufacturer.(3) Although a single IM dose of 1 mg/kg in infants and administration 1.8 mg/kg in children has been used,(21) rocuronium should not be used as an alternative to IM succinylcholine when rapid intubation is necessary. The use of IM administration is not recommended since it does not consistently provide satisfactory tracheal intubating conditions.(21) When given in the deltoid muscle of infants and children, serum concentra- tions peak at 13 minutes, with about 80% of the dose absorbed systemically.(22)

Comments Significant adverse effects: Prolonged neuromuscular blockade may occur. Factors that potentiate the duration of neuromuscular blockade include acidosis, hypokalemia, hypermagnesemia, neuromuscular disease, hepatic disease, and other medications.(3,12) (See Drug Interactions below.) Patients with neurological diseases, such as myasthenia gravis, may exhibit increased sensitivity.(3) One case report describes an 18-year-old with Kugelberg-Welander syn- drome (a type III spinal muscular atrophy) undergoing elective surgery. A single dose of rocuronium 25 mg (0.83 mg/kg) along with general anesthesia facilitated intubation.(25) Decreased sensitivity to rocuronium may occur in patients with severe burns, muscle trauma, demyelinating lesions, neuropathy, or infection.(3) Drug interactions: Concomitant administration of other drugs (e.g., aminoglycosides, inhalational anesthetics, magnesium, succinylcholine, vancomycin) may prolong neuro- muscular blockade.(3) Consult appropriate resources for additional information on drug interactions. In children with cerebral palsy undergoing orthopedic surgery, total rocuronium requirements were reduced by adding magnesium sulfate 50 mg/kg bolus followed by 15 mg/kg/hr.(26) Other: For neonatal nonemergent intubations, AAP recommends that vagolytic and agents should be considered and that analgesic agents or anesthetic doses of a hypnotic agent should be administered. Rocuronium or vecuronium is preferred over other available neuromuscular blocking agents.(10) Trials comparing rocuronium doses in patients receiving concomitant anesthet- ics for intubation prior to surgery: In children undergoing tonsillectomy with propofol and alfentanil anesthesia, lower-dose rocuronium (0.45 mg/kg) produced good intubating conditions, a shorter recovery time, but a slightly prolonged onset of action compared to 0.6 mg/kg rocuronium or 0.1 mg/kg of vecuronium.(23) Conversely, in children undergo- ing elective surgery with halothane anesthesia, rocuronium 0.45 mg/kg was inferior to 0.6 mg/kg for producing satisfactory intubating conditions.(17) In children 4–8 years old undergoing elective surgery, rocuronium 0.6 mg/kg with propofol 2.5 mg/kg provided acceptable intubating conditions.(24)  769