Note: Dose to effect; doses will vary due to interpatient variability. Ensure adequate pain control and sedation prior to and during administration of neuromuscular blockade to achieve deep sedation (SCCM [Murray 2016]).
Endotracheal intubation or mechanical ventilation during surgery, neuromuscular blockade (adjunctive therapy): Note: Inhaled anesthetic agents prolong the duration of action of rocuronium. Use lower end of the dosing range; redosing interval guided by monitoring with a peripheral nerve stimulator.
Rapid sequence intubation: IV: 1.2 to 1.5 mg/kg; administration of 1.5 mg/kg may provide optimal conditions for tracheal intubation (Guihard 2019; Levin 2021; Tang 2022).
Tracheal intubation, non-emergent:
Initial: IV: 0.6 to 1 mg/kg; usual dosage range: 0.45 to 1.2 mg/kg, depending on desired onset and duration (Honing 2021; manufacturer's labeling).
Maintenance: IV: 0.1 to 0.2 mg/kg; repeat bolus as needed or start a continuous infusion of 5 to 16 mcg/kg/minute; adjust at 15-minute intervals by ~1.5 to 3 mcg/kg/minute; usual dosage range: 4 to 16 mcg/kg/minute (Honing 2021; Ko 2018; Veelo 2019; Zhang 2022; manufacturer's labeling).
Mechanically ventilated patients in the ICU, neuromuscular blockade (off-label use): Note: May use to facilitate mechanical ventilation (eg, moderate to severe acute respiratory distress syndrome [ARDS]), for refractory, life-threatening status asthmaticus, or for shivering from therapeutic hypothermia (Alhazzani 2020; SCCM [Evans 2021]; SCCM [Murray 2016]).
Continuous infusion: IV: Initial: Loading dose of 0.6 to 1 mg/kg, followed by continuous infusion of 3 to 8 mcg/kg/minute for up to 48 hours; adjust rate by 0.5 to 1 mcg/kg/minute every 60 minutes according to desired clinical response and/or peripheral nerve stimulation; usual dosage range: 3 to 16 mcg/kg/minute (Aldhaeefi 2021; Alhazzani 2020; SCCM [Murray 2002]; manufacturer's labeling).
Intermittent dosing: IV: Initial: Loading dose of 0.6 to 1 mg/kg (or 50 mg); may repeat with 0.3 to 1 mg/kg (or 25 mg) every 30 to 60 minutes according to desired clinical response (SCCM [Murray 2002]; Sparr 1997; manufacturer's labeling).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
No dosage adjustment necessary. Duration of neuromuscular blockade may vary in patients with kidney impairment.
No dosage adjustment provided in manufacturer's labeling. However, dosage reductions may be necessary in patients with liver disease; duration of neuromuscular blockade may be prolonged due to increased volume of distribution. When rapid sequence intubation is required in adult patients with ascites, a dose on the higher end of the dosage range may be necessary to achieve adequate neuromuscular blockade.
(For additional information see "Rocuronium: Pediatric drug information")
Note: Dose to effect; doses will vary due to interpatient variability. Dosing also dependent on anesthetic technique and age of patient. In general, the onset of effect is shortened and duration is prolonged as the dose increases. The time to maximum nerve block is shortest in infants 1 to 3 months; the duration of relaxation is shortest in children 2 to 11 years and longest in infants. The manufacturer recommends dosing based on actual body weight in all obese patients; however, some have recommended dosing based on ideal body weight (IBW) in obese patients (Playfor 2007).
Rapid sequence intubation:
Infants: IV: Usual: 1 mg/kg, range: 0.6 to 1.2 mg/kg (Bledsoe 2004; Shenoi 2020).
Children and Adolescents: IV: 0.9 to 1.2 mg/kg; Note: Lower doses of 0.6 mg/kg have been reported in the literature; however, some studies found this dosing resulted in prolonged time to onset, shortened duration of neuromuscular blockade and less favorable intubating conditions (Cheng 2002; Fuchs-Buder 1996; Mazurek 1998; Naguib 1997).
Tracheal intubation, surgical: Infants, Children, and Adolescents: Note: Inhaled anesthetic agents prolong the duration of action of rocuronium; use lower end of the dosing range; dosing interval guided by monitoring with a peripheral nerve stimulator.
Initial:
IV: 0.45 to 0.6 mg/kg.
IM (Kaplan 1999): Limited data available: Note: Due to the prolonged time to onset in some patients, IM dosing may not be ideal for rapid sequence intubation for the general population and should be reserved to clinical scenarios when alternative agents are not appropriate.
Infants ≥3 months: 1 mg/kg administered as a single dose.
Children 1 to 6 years: 1.8 mg/kg administered as a single dose.
Maintenance for continued surgical relaxation:
Intermittent IV dosing: Infants, Children, and Adolescents: 0.075 to 0.15 mg/kg; repeat as needed.
Continuous IV infusion: Infants, Children, and Adolescents: 7 to 12 mcg/kg/minute (0.42 to 0.72 mg/kg/hour); the manufacturer recommends using the lower end of the dosing range for infants and the upper end for children >2 to ≤11 years of age; higher doses have been reported with prolonged infusions (Tobias 1996).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Infants, Children, and Adolescents: No dosage adjustment necessary; duration of neuromuscular blockade may vary in patients with renal impairment.
Infants, Children, and Adolescents: There are no dosage adjustments provided in the manufacturer's labeling; however, dosage reductions may be necessary in patients with liver disease; duration of neuromuscular blockade may be prolonged due to increased volume of distribution. When rapid sequence intubation is required in adult patients with ascites, a dose on the higher end of the dosage range may be necessary to achieve adequate neuromuscular blockade.
Refer to adult dosing.
The recommendations for dosing in patients with obesity are based upon the best available evidence and clinical expertise. Senior Editorial Team: Jeffrey F. Barletta, PharmD, FCCM; Manjunath P. Pai, PharmD, FCP; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC.
Class 1, 2, and 3 obesity (BMI ≥30 kg/m2):
IV: Use ideal body weight for weight-based dose calculations (Gaszynski 2011; Meyhoff 2009; Patanwala 2017). In patients with extreme obesity (eg, BMI ≥50 kg/m2), or when underdosing is a concern, consider using adjusted body weight for weight-based dosing calculations; however, duration of action may be prolonged (expert opinion). Clinicians should not change dosing weight from one weight metric to another during therapy (ie, actual body weight to/from either adjusted body weight or ideal body weight) (expert opinion). Refer to adult dosing for indication-specific doses. If using repeat dosing or continuous infusion after administration of initial dose, titrate to clinical effect.
Rationale for recommendations
Nondepolarizing neuromuscular blocking agents (NMBAs) are hydrophilic compounds with a small Vd, thus distribution of rocuronium into adipose tissue is limited (Pühringer 1999). There are no studies evaluating the most appropriate weight metric in patients with obesity receiving sustained continuous infusions. Data with NMBAs in patients with obesity predominantly originate from studies evaluating either single bolus or incremental doses in patients undergoing surgical procedures.
Although the manufacturer label suggests actual body weight for weight-based dosing, studies in patients with obesity where rocuronium was dosed according to actual body weight have demonstrated prolonged recovery times compared to weight-based dosing using other weight measures (eg, ideal body weight [IBW]) (Fujimoto 2013; Jing 2017; Leykin 2004; Sakızcı-Uyar 2016). One study randomized patients with obesity (BMI ~44 kg/m2) to receive 0.6 mg/kg based on IBW or adjusted body weight (AdjBW) calculated using a correction factor of 0.2 or 0.4. This study showed no difference in onset of effect or intubation conditions among the 3 groups. The time to recovery was ~150% longer in the AdjBW (using 0.4 correction factor) group compared to the IBW group (Meyhoff 2009).
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Intravenous, as bromide:
Generic: 50 mg/5 mL (5 mL); 100 mg/10 mL (10 mL)
Solution, Intravenous, as bromide [preservative free]:
Generic: 50 mg/5 mL (5 mL); 100 mg/10 mL (10 mL)
Yes
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution, Intravenous:
Generic: 10 mg/mL (5 mL, 10 mL)
Solution, Intravenous, as bromide:
Generic: 50 mg/5 mL (5 mL)
IV: May be administered as a bolus injection (undiluted) or via a continuous infusion.
Parenteral:
IM: Administer undiluted by rapid IM injection into the deltoid muscle (Kaplan 1999; Reynolds 1996)
IV: May be administered undiluted by rapid IV injection; or further diluted and infused as a continuous IV infusion
Endotracheal intubation or mechanical ventilation during surgery, neuromuscular blockade: As an adjunct to general anesthesia to facilitate rapid sequence and routine tracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation in adequately sedated ICU patients.
Note: Neuromuscular blockade does not provide pain control, sedation, or amnestic effects. Appropriate analgesic and sedative mediations should be used before and during administration of neuromuscular blockade to achieve deep sedation.
Mechanically ventilated patients in the ICU, neuromuscular blockade
Zemuron may be confused with Remeron, Zemplar.
The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.
According to the 2020 to 2021 ISMP Targeted Medication Safety Best Practices for Hospitals, neuromuscular blockers should be segregated, sequestered, and differentiated from all other medication wherever they are stored. This includes:
- Only storing in places within the hospital that they are routinely used.
- Placing in sealed boxes or in rapid sequence intubation kits (preferred).
- Limiting availability in automated dispensing cabinets to perioperative, labor and delivery, critical care, and emergency departments only.
- Placing in separate lidded containers within the pharmacy refrigerator or other isolated pharmacy storage area.
- Affixing an auxiliary label to clearly communicate respiratory paralysis will occur and ventilation required on all storage bins and/or automated dispensing pockets/drawers (exception anesthesia-prepared syringes) stating one of the following:
Warning: Causes Respiratory Arrest – Patient Must Be Ventilated.
Warning: Paralyzing Agent – Causes Respiratory Arrest.
Warning: Causes Respiratory Paralysis – Patient Must Be Ventilated.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Frequency not always defined.
Cardiovascular: Increased peripheral vascular resistance (abdominal aortic surgery: 24%, frequency not defined during other procedures), tachycardia (≤5%; incidence greater in children), hypertension, transient hypotension
Hypersensitivity: Anaphylaxis
<1%, postmarketing, and/or case reports: Anaphylactoid reaction, asthma, cardiac arrhythmia, ECG abnormality, edema at insertion site, hiccups, nausea, pruritus, skin rash, vomiting
Hypersensitivity (eg, anaphylaxis) to rocuronium, other neuromuscular-blocking agents, or any component of the formulation
Concerns related to adverse effects:
• Anaphylactoid/hypersensitivity reactions: Have been reported; immediate treatment (including epinephrine 1 mg/mL) for anaphylactoid and/or hypersensitivity reactions should be available during use.
• Neuromuscular cross-sensitivity: Cross-sensitivity with other neuromuscular-blocking agents may occur; use is contraindicated in patients with previous anaphylactic reactions to other neuromuscular blockers.
• Prolonged paralysis: Some patients may experience prolonged recovery of neuromuscular function after administration (especially after prolonged use). Patients should be adequately recovered prior to extubation. Other factors associated with prolonged recovery should be considered (eg, corticosteroid use, patient condition).
Disease-related concerns:
• Burn injury: Resistance may occur in burn patients (≥20% of total body surface area), usually several days after the injury, and may persist for several months after wound healing (Han 2009).
• Cardiovascular disease: Use with caution in patients with cardiovascular disease (eg, heart failure); onset of action may be delayed and duration of action may be prolonged.
• Conditions that may antagonize neuromuscular blockade (decreased paralysis): Respiratory alkalosis, hypercalcemia, demyelinating lesions, peripheral neuropathies, denervation, and muscle trauma may result in antagonism of neuromuscular blockade (ACCM/SCCM/ASHP [Murray 2002]; Greenberg 2013; Miller 2010; Naguib 2002).
• Conditions that may potentiate neuromuscular blockade (increased paralysis): Electrolyte abnormalities (eg, severe hypocalcemia, severe hypokalemia, hypermagnesemia), cachexia, neuromuscular diseases, metabolic acidosis, respiratory acidosis, Eaton-Lambert syndrome, and myasthenia gravis may result in potentiation of neuromuscular blockade (Greenberg 2013; Miller 2010; Naguib 2002).
• Hepatic impairment: Use with caution in patients with hepatic impairment; clinical duration may be prolonged.
• Pulmonary hypertension: Use with caution in patients with pulmonary hypertension; use may increase pulmonary vascular resistance worsening symptoms of right heart failure.
• Respiratory disease: Use with caution in patients with respiratory disease.
• Valvular heart disease: Use with caution in patients with valvular heart disease; use may increase pulmonary vascular resistance.
Special populations:
• Older adults: Use with caution in older adults, effects and duration are more variable.
• Immobilized patients: Resistance may occur in patients who are immobilized.
• Pediatric: Not recommended by the manufacturer for rapid sequence intubation in pediatric patients; however, it has been used successfully in clinical trials for this indication (Cheng 2002; Fuchs-Buder 1996; Mazurek 1998; Naguib 1997).
Other warnings/precautions:
• Appropriate use: Maintenance of an adequate airway and respiratory support is critical. Tolerance to rocuronium may develop. All patients should receive eye care including liberal use of lubricating drops, gel, or ointment and eyelids should remain closed during continuous neuromuscular blockade to protect against damage to the cornea (ulceration and drying).
• Experienced personnel: Should be administered by adequately trained individuals familiar with its use.
• Extravasation: If extravasation occurs, local irritation may ensue; discontinue administration immediately and restart in another vein.
• Risk of medication errors: Accidental administration may be fatal. Confirm proper selection of intended product, store vial so the cap and ferrule are intact and the possibility of selecting the wrong product is minimized, and ensure that the intended dose is clearly labeled and communicated, when applicable.
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Acetylcholinesterase Inhibitors: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy
Aminoglycosides: May enhance the therapeutic effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Bacitracin (Systemic): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Botulinum Toxin-Containing Products: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Bromperidol: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Calcium Channel Blockers: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy
Capreomycin: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
CarBAMazepine: May decrease the serum concentration of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy
Cardiac Glycosides: Neuromuscular-Blocking Agents may enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy
Clindamycin (Topical): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Colistimethate: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Management: If possible, avoid concomitant use of these products. Monitor for deeper, prolonged neuromuscular-blocking effects (respiratory paralysis) in patients receiving concomitant neuromuscular-blocking agents and colistimethate. Risk D: Consider therapy modification
Corticosteroids (Systemic): Neuromuscular-Blocking Agents (Nondepolarizing) may enhance the adverse neuromuscular effect of Corticosteroids (Systemic). Increased muscle weakness, possibly progressing to polyneuropathies and myopathies, may occur. Management: If concomitant therapy is required, use the lowest dose for the shortest duration to limit the risk of myopathy or neuropathy. Monitor for new onset or worsening muscle weakness, reduction or loss of deep tendon reflexes, and peripheral sensory decriments Risk D: Consider therapy modification
CycloSPORINE (Systemic): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
EPHEDrine (Systemic): May enhance the therapeutic effect of Rocuronium. Risk C: Monitor therapy
Fosphenytoin-Phenytoin: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Fosphenytoin-Phenytoin may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Fosphenytoin-Phenytoin may decrease the serum concentration of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy
Inhalational Anesthetics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Management: When initiating a non-depolarizing neuromuscular blocking agent (NMBA) in a patient receiving an inhalational anesthetic, initial NMBA doses should be reduced 15% to 25% and doses of continuous infusions should be reduced 30% to 60%. Risk D: Consider therapy modification
Ketorolac (Nasal): May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents (Nondepolarizing). Specifically, episodes of apnea have been reported in patients using this combination. Risk C: Monitor therapy
Ketorolac (Systemic): May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents (Nondepolarizing). Specifically, episodes of apnea have been reported in patients using this combination. Risk C: Monitor therapy
Lincosamide Antibiotics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Lithium: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Local Anesthetics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Loop Diuretics: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Loop Diuretics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Magnesium Salts: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Minocycline (Systemic): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Pholcodine: May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents. Specifically, anaphylaxis has been reported. Risk C: Monitor therapy
Polymyxin B: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Management: If possible, avoid concomitant use of neuromuscular-blocking agents and polymyxin B. If concomitant use cannot be avoided, monitor for deeper, prolonged neuromuscular-blocking effects (eg, respiratory paralysis) in patients receiving this combination. Risk D: Consider therapy modification
Procainamide: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
QuiNIDine: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
QuiNINE: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk X: Avoid combination
Tetracyclines: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Thiazide and Thiazide-Like Diuretics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy
Trimebutine: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy
Vancomycin: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Rocuronium crosses the placenta; umbilical venous plasma levels are ~18% of the maternal concentration following a maternal dose of 0.6 mg/kg (Abouleish 1994). The manufacturer does not recommend use for rapid sequence induction during cesarean section.
Information related to rocuronium use and breast-feeding has not been located. If present in breast milk, oral absorption by a nursing infant would be expected to be minimal (Lee 1993).
Vital signs (heart rate, blood pressure, respiratory rate); degree of muscle paralysis (eg, presence of spontaneous movement, ventilator asynchrony, shivering, and consider use of a peripheral nerve stimulator with train of four monitoring along with clinical assessments)
In the ICU setting, prolonged paralysis and generalized myopathy, following discontinuation of agent, may be minimized by appropriately monitoring degree of blockade.
Blocks acetylcholine from binding to receptors on motor endplate inhibiting depolarization
Onset of action:
Infants ≥3 months and Children: 30 seconds to 1 minute.
Adults: Good intubation conditions within 1 to 3 minutes (dose dependent); maximum neuromuscular blockade within 4 minutes.
Duration:
Infants: 3 to 12 months: 40 minutes.
Children: 1 to 12 years: 26 to 30 minutes.
Adults: ~20 to 70 minutes (dose dependent, increases with higher doses and inhalational anesthetic agents); hypothermia may prolong the duration of action.
Distribution: Vd:
Children: 0.21 to 0.3 L/kg.
Adults: 0.25 L/kg.
Hepatic dysfunction: 0.53 L/kg.
Kidney dysfunction: 0.34 L/kg.
Protein binding: ~30%.
Metabolism: Minimally hepatic; 17-desacetylrocuronium (5% to 10% activity of parent drug).
Half-life elimination:
Alpha elimination: 1 to 2 minutes.
Beta elimination:
Infants 3 to 12 months: 1.3 ± 0.5 hours.
Children 1 to <3 years: 1.1 ± 0.7 hours.
Children 3 to <8 years: 0.8 ± 0.3 hours.
Adults: 1.4 to 2.4 hours.
Hepatic impairment: 4.3 hours.
Kidney impairment: 2.4 hours.
Excretion: Feces (50% to 75%); urine (10% to 30%) (Price 2012).
Clearance: Pediatric patients:
Infants 3 to <12 months: 0.35 L/kg/hour.
Children 1 to <3 years: 0.32 L/kg/hour.
Children 3 to <8 years: 0.44 L/kg/hour.
Altered kidney function: Patients with kidney failure have clinical durations that are similar to but somewhat more variable than what is expected in patients with normal kidney function.
Hepatic function impairment: Patients with clinically significant hepatic impairment had moderately prolonged clinical duration; patients with cirrhosis had increased Vd, prolonged plasma half-life, and >2.5 times the recovery time compared to patients with normal hepatic function.
Older adults: Onset time and duration of action are slightly longer in older adults.
Solution (Rocuronium Bromide Intravenous)
50 mg/5 mL (per mL): $0.59 - $3.93
100 mg/10 mL (per mL): $0.60 - $3.78
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
