High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error.
neuromuscular blocking agents-nondepolarizing
- Induction of skeletal muscle paralysis and facilitation of intubation after induction of anesthesia in surgical procedures.
- Facilitation of compliance during mechanical ventilation.
Prevents neuromuscular transmission by blocking the effect of acetylcholine at the myoneural junction. Has no analgesic or anxiolytic properties
Skeletal muscle paralysis.
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)
|IV||1 min||0.5–1 min (peds) 1–3.7 min (adults)||26–40 min (peds) 31 min (adults)*|
Use Cautiously in:
- Dehydration or electrolyte abnormalities (should be corrected)
- Fractures or muscle spasm
- Hyperthermia (↑ duration/intensity of paralysis)
- Significant hepatic impairment
- 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: Use during pregnancy only if potential maternal benefit justifies potential fetal risk
- 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
Misc: HYPERSENSITIVITY REACTIONS (including anaphylaxis)
* CAPITALS indicate life-threatening.
Underline indicate most frequent.
- 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.
IV (Adults): Rapid sequence tracheal intubation– 0.6–1.2 mg/kg; Maintenance dosing– 0.1–0.2 mg/kg, repeat doses as needed; Continuous infusion– 10–12 mcg/kg/min (range 4–16 mcg/kg/min).
IV (Children ≥3 mo): Intubation dose– 0.6 mg/kg; Maintenance dose– 0.075–0.125 mg/kg; Continuous infusion– 12 mcg/kg/min.
Availability (generic available)
Solution for injection: 10 mg/mL
- 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 and 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 Push: Administer undiluted.
- Rate: Titrate according to patient response.
- Continuous Infusion: Dilution: 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:
- aminocaproic acid
- calcium chloride
- calcium gluconate
- etoposide phosphate
- hydrocortisone sodium phosphate
- magnesium hydroxide
- potassium acetate
- potassium chloride
- sodium acetate
- sodium bicarbonate
- sodium phosphate
- zoledronic acid
- Y-Site Incompatibility:
- amphotericin B lipid complex
- hydrocortisone sodium succinate
- potassium phosphate
- 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.
- 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.