Rocuronium Bromide (rocuronium bromide)

Dosage of rocuronium bromide is expressed in terms of the salt. The dosage must be adjusted carefully according to individual requirements and response. 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.

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. Potentiation is minimal when rocuronium is administered prior to these anesthetics.

Rocuronium bromide is administered IV only.

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.

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). The infusion solution should be used within 24 hours of preparation. 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.

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

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

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

No dosing information is available for this tab.

No dosing information is available for this tab.

There is no enhanced messaging for this drug.

There are no contraindication interactions for this drug.

Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

Neuromuscular Blocking Agents/Misc Antibiotics

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Aminoglycosides, bacitracin, clindamycin, lincomycin, and polymyxins may enhance the pharmacologic effects of neuromuscular blocking agents.

CLINICAL EFFECTS: May see an increase in the pharmacologic effects of neuromuscular blocking agents, including prolonged respiratory depression and apnea.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: If it is necessary to administer these drugs concurrently, do so with extreme caution. Monitor neuromuscular function and adjust the dose of the neuromuscular blocking agent accordingly.

DISCUSSION: Concomitant administration of aminoglycosides, bacitracin, clindamycin, lincomycin, and polymixins with neuromuscular blocking agents has been shown to produce synergism of the effects on skeletal muscles. Concurrent administration of these drugs has been associated with prolonged respiratory depression, respiratory paralysis, and fatal apnea. The interaction usually occurs when the antibiotic is given prior to or concurrently with the neuromuscular blocking drug, but it may also occur when given after administration. Any antibiotic dosage or route of administration may produce respiratory depression.

Neuromuscular Blocking Agents/Quinine Derivatives

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Synergistic or additive pharmacologic activity.

CLINICAL EFFECTS: May see an increase in the neuromuscular blocking effects, including profound sedation, respiratory depression, coma, and/or death.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Avoid concurrent administration of neuromuscular blocking agents and quinine derivatives during the first several hours of postoperative period. If administered, respiratory support may be needed. If concurrent use is necessary, monitor patients for unusual dizziness or lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness.

DISCUSSION: Administration of quinidine during the immediate postoperative period has been associated with respiratory paralysis and apnea.

Neuromuscular Blocking Agents/Verapamil

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Unknown.

CLINICAL EFFECTS: The neuromuscular blocking effect of nondepolarizing muscle relaxants may be extended, producing profound sedation, respiratory depression, coma, and/or death.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: If possible, avoid administration of nondepolarizing neuromuscular blocking agents to patients receiving verapamil. When both drugs must be given, carefully monitor respiratory function to avoid prolonged neuromuscular blockade. If needed, blockade may be reversed by giving edrophonium. If concurrent use is necessary, monitor patients for unusual dizziness or lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness.

DISCUSSION: Patients receiving verapamil have experienced prolonged skeletal muscle paralysis after administration of usual therapeutic doses of a nondepolarizing neuromuscular blocking agent. While muscle paralysis was unresponsive to treatment with neostigmine, reversal of blockade has been achieved by administration of edrophonium.

Moderate Interaction: Assess the risk to the patient and take action as needed.

Neuromuscular Blocking Agents/Lincosamides

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Lincosamides appear to augment the neuromuscular blocking effects of nondepolarizing muscle relaxants.

CLINICAL EFFECTS: The effects of nondepolarizing neuromuscular relaxants may be prolonged leading to profound sedation, respiratory depression, coma, and/or death.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Monitor respiratory function of the patient and provide the necessary support. In patients who have received nondepolarizing muscle relaxants, avoid use of lincosamides in the recovery room. If concurrent use is necessary, monitor patients for unusual dizziness or lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness.

DISCUSSION: Lincomycin has been reported to augment the neuromuscular blocking effect of pancuronium in seven anesthetized patients. The effect was readily antagonized by neostigmine administration. In a case report, clindamycin produced prolonged neuromuscular blockade in a patient who had received pancuronium. Neostigmine was ineffective in antagonizing the blockade.

Neuromuscular Blocking Agents/Polypeptide Antibiotics

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Synergistic pharmacologic activity. Polymyxin B affects neuromuscular transmission by blocking acetylcholine receptors. Its action is thus post-synaptic and the neuromuscular block has no antagonists. Polymyxin B causes neostigmine resistance to d-tubocurarine blockade and calcium resistance to the blockade evoked by aminoglycoside antibiotics (1,2,3,4). A pre-synaptic mechanism may also be involved with decreased release of acetylcholine.

CLINICAL EFFECTS: May see an increase in the neuromuscular blocking effects, including profound sedation, respiratory depression, coma, and/or death.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: If it is necessary to administer these drugs concurrently, do so with extreme caution. Monitor neuromuscular function and adjust the dose of the neuromuscular blocking agent accordingly. If concurrent use is necessary, monitor patients for unusual dizziness or lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness.

DISCUSSION: Concomitant administration of polypeptide antibiotics and neuromuscular blocking agents has been shown to produce synergism of the effects on skeletal muscles. Concurrent administration of these drugs has been associated with prolonged respiratory depression, respiratory paralysis, and apnea. This interaction has been documented with colistimethate, polymyxin B, bacitracin, and vancomycin.

Nondepolarizing Muscle Relaxants/Magnesium Salts, Injectable

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Magnesium may reduce postjunctional membrane neuromuscular blocking action of nondepolarizing muscle relaxants. Parenterally administered magnesium may potentiate the effects of the nondepolarizing muscle relaxants.

CLINICAL EFFECTS: Increased neuromuscular blockade with profound sedation, respiratory depression, coma, and/or death.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Monitor respiratory function when parenteral magnesium and nondepolarizing muscle relaxants are administered concurrently. Adjust the dose of the neuromuscular blocking agent accordingly. If concurrent use is necessary, monitor patients for unusual dizziness or lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness.

DISCUSSION: The effects of nondepolarizing muscle relaxants have been reported to be increased in laboratory animals and in humans by concomitant administration of magnesium sulfate. Respiratory depression has been reported.

Select Neuromuscular Blocking Agents/Hydantoins

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: It has been suggested that phenytoin increases end-plate anticholinesterase activity, resulting in higher acetylcholine concentration at the neuromuscular junction.(1)

CLINICAL EFFECTS: A higher plasma concentration of the neuromuscular blocking agent was required to effect a given level of neuromuscular blockade in patients receiving phenytoin.(2,3)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Patients receiving hydantoin anticonvulsants should be monitored for a decreased response to the neuromuscular blocking agent. The dose of the neuromuscular blocking agent may need to be increased and/or given more frequently.(9)

DISCUSSION: In a study, patients receiving phenytoin were administered metocurine, attained 83% of maximum neuromuscular blockade compared with 98% in the control group.(1) In another study, patients maintained on phenytoin for more than one week had a significantly higher pancuronium requirement than those patients not receiving phenytoin.(1) In two separate case reports, patients maintained on phenytoin demonstrated a resistance to pancuronium and a decreased duration of neuromuscular blockade.(3,4) In a study, patients maintained on phenytoin and receiving vecuronium had a significantly shorter total duration and effect of neuromuscular blockade compared to those patients not receiving phenytoin.(5) In contrast, neither the effect nor duration of atracurium's neuromuscular blockade was affected by phenytoin.(5) Two in vitro studies showed that the neuromuscular blockade of curare and tubocurarine was potentiated by the use of phenytoin.(6,7) Ten children received a bolus dose of vecuronium 0.15mg/Kg while on phenytoin and showed a significantly increased clearance of vecuronium compared to the control group, 15.1 and 9.0 ml/Kg/min, respectively.(8) In a case report, a 58 year-old male previously stabilized on phenytoin (400 mg daily) was given an injection of vecuronium (8 mg) to induce muscle blockade during bowel surgery. While monitoring the effectiveness of vecuronium only 75% twitch height blockade was noted after seven minutes. The medication, due to its short duration and impaired effectiveness, had to be given more frequently throughout the surgery in order to maintain adequate muscle block.(9) A separate case report records a decreased response to pancuronium in a 15 year-old male, previously stabilized on phenytoin (350 mg daily), while undergoing surgery to remove a parietal tumor. Pancuronium (0.7 mg/kg) was given as a relaxant during the surgery and monitored using the train-of-four method. Intermittent doses of pancuronium (0.17 mg/kg) were given for the first hour of surgery without successful blockade apparent by the return of all four twitches within ten minutes of each dose. A second attempt at muscular blockade was made with continuous infusion atracurium (0.26-0.55 mg/kg/hour) for the duration of the surgery. Only 16 minutes after stopping the infusion, all four twitches were visible.(10)

*Known hypersensitivity to the drug or other neuromuscular blocking agents.

There are no contraindication contraindications for this drug.

• Eaton-lambert syndrome
• Malignant hyperthermia
• Myasthenia gravis
• Pulmonary hypertension

• Acidosis
• Alkalosis
• Disease of liver
• Hypocalcemia
• Hypokalemia
• Hypomagnesemia
• Kidney disease with reduction in glomerular filtration rate (GFr)
• Respiratory acidosis
• Respiratory alkalosis

The most common adverse effects of rocuronium observed in 2% of patients in clinical studies were transient hypotension and hypertension.

Less Frequent

• Hypertension
• Hypotension

Rare or Very Rare

• Abnormal ECG
• Anaphylaxis
• Asthma
• Bronchospastic pulmonary disease
• Cardiac arrhythmia
• Malignant hyperthermia
• Myopathy
• Pulmonary hypertension
• Skin rash
• Tachycardia

More Frequent

• Injection site sequelae

Rare or Very Rare

• Hiccups
• Mydriasis
• Nausea
• Pruritus of skin
• Vomiting

No enhanced messaging available.

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. 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.

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.

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

There are no adequate and well-controlled studies of rocuronium in pregnant women. In animal studies, teratogenicity was not observed. High-dose rocuronium was associated with acute symptoms of respiratory dysfunction in pregnant, conscious, non-ventilated rabbits and rats. 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. Use rocuronium during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Rocuronium has been used in a limited number of pregnant women undergoing cesarean section. 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.

No information is available regarding the use of rocuronium in lactating patients.

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). 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.

Rocuronium has been evaluated in geriatric patients >=65 years of age in clinical studies. 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. 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.