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Rocuronium: Drug information

Rocuronium: Drug information
2024© UpToDate, Inc. and its affiliates and/or licensors. All Rights Reserved.
For additional information see "Rocuronium: Patient drug information" and "Rocuronium: Pediatric drug information"

For abbreviations, symbols, and age group definitions show table
Pharmacologic Category
  • Neuromuscular Blocker Agent, Nondepolarizing
Dosing: Adult

Dosage guidance:

Dosing: Doses must be individualized due to interpatient variability, patient specific-factors, and/or comorbidities (eg, severe trauma, burn injury) (Ref).

Endotracheal intubation

Note: Ensure adequate pain control and sedation prior to and during administration of neuromuscular blockade.

Endotracheal intubation: IV: 0.6 to 1 mg/kg once; usual dosage range: 0.45 to 1.2 mg/kg, depending on desired onset and duration (Ref).

Rapid sequence intubation, neuromuscular blockade: IV: 1 to 1.2 mg/kg once (Ref); some experts prefer to use 1.5 mg/kg once, as it may provide higher rates of first-attempt success in most patients and in those with suspected NMBA receptor resistance (eg, burn population); however, these larger doses increase the duration of action (Ref).

Mechanically ventilated patients in the ICU, neuromuscular blockade

Mechanically ventilated patients in the ICU, neuromuscular blockade: Note: Ensure adequate pain control and sedation prior to and during administration of neuromuscular blockade. May use to facilitate mechanical ventilation (eg, refractory moderate to severe acute respiratory distress syndrome; refractory, life-threatening status asthmaticus; shivering from therapeutic hypothermia) (Ref). Refer to institutional protocols. Titration specifics may vary; a titration example is provided below.

Continuous infusion: IV: 0.6 to 1 mg/kg initial loading dose, followed by continuous infusion of 3 to 8 mcg/kg/minute; titrate by 0.5 to 1 mcg/kg/minute every 60 minutes based on clinical response and neuromuscular monitoring (eg, train-of-four); usual dosage range: 3 to 16 mcg/kg/minute (Ref).

Intermittent dose: IV: 0.6 to 1 mg/kg (or 50 mg) initial loading dose, followed by 0.3 to 1 mg/kg (or 25 mg) every 30 to 60 minutes based on clinical response and neuromuscular monitoring (eg, train-of-four) (Ref).

Neuromuscular blockade during general anesthesia

Neuromuscular blockade during general anesthesia (adjunctive therapy):

Maintenance dosing: Note: Inhaled anesthetic agents (eg, desflurane, isoflurane, sevoflurane) prolong the duration of action of rocuronium and may potentiate the neuromuscular blockade.

Continuous infusion: IV: 5 to 12 mcg/kg/minute as an initial continuous infusion; titrate as needed based on clinical response and neuromuscular monitoring (eg, train-of-four); usual dosage range: 5 to 16 mcg/kg/minute (Ref).

Intermittent dose: IV: 0.1 to 0.2 mg/kg; repeat as needed based on clinical response and neuromuscular monitoring (eg, train-of-four) (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

Note: Although kidney elimination is not the primary route of elimination in patients without kidney dysfunction (predominantly eliminated via the biliary route), decreased clearance (up to 39%) and a prolonged recovery time (up to 84%) have been observed in some studies in patients with severe kidney dysfunction compared to healthy controls (Ref).

Altered kidney function:

CrCl ≥30 mL/minute: No dosage adjustment necessary (Ref).

CrCl <30 mL/minute: No dosage adjustment necessary; however, consider alternative agents or use with caution due to increased interpatient variability and less predictable duration of action (Ref).

Hemodialysis, intermittent (thrice weekly): Likely to be dialyzed (extent unknown): No dosage adjustment necessary (Ref); however, consider alternative agents or use with caution due to increased interpatient variability and less predictable duration of action seen in patients with severe kidney dysfunction (Ref).

Peritoneal dialysis: Likely to be dialyzed (extent unknown): No dosage adjustment necessary (Ref); however, consider alternative agents or use with caution due to increased interpatient variability and less predictable duration of action seen in patients with severe kidney dysfunction (Ref)

CRRT: No dosage adjustment necessary (Ref); however, consider alternative agents or use with caution due to increased interpatient variability and less predictable duration of action seen in patients with severe kidney dysfunction (Ref).

PIRRT (eg, sustained, low-efficiency diafiltration): No dosage adjustment necessary (Ref); however, consider alternative agents or use with caution due to increased interpatient variability and less predictable duration of action seen in patients with severe kidney dysfunction (Ref).

Dosing: Hepatic Impairment: Adult

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.

Dosing: Obesity: Adult

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 (Ref). 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 (Ref). In rare situations when emergent therapy is needed (eg, rapid sequence intubation) and adjusted body weight cannot be rapidly calculated, actual body weight may be considered for dose calculations but doses of >250 mg are rarely, if ever, needed (Ref). 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) (Ref). 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 (Ref). 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]) (Ref). 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 (Ref).

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(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 (Ref).

Neuromuscular blockade

Neuromuscular blockade:

ICU paralysis (eg, facilitate mechanical ventilation): Limited data available (Ref):

Infants, Children, and Adolescents:

Intermittent IV dosing: IV: 0.6 mg/kg; repeat as needed.

Continuous IV infusion: 5 to 17 mcg/kg/minute (0.3 to 1 mg/kg/hour).

Adjunct to surgical anesthesia: 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 dosing:

IV: Infants, Children, and Adolescents: IV: 0.45 to 0.6 mg/kg.

IM: Limited data available (Ref): Note: Due to the prolonged time to onset in some patients, IM dosing may not be ideal for tracheal intubation for the general population and should be reserved to clinical scenarios when alternative agents are not appropriate or IV access is not available.

Infants ≥3 months: IM: 1 mg/kg administered as a single dose.

Children 1 to <6 years: IM: 1.8 mg/kg administered as a single dose.

Maintenance for continued surgical relaxation:

Intermittent IV dosing: Infants, Children, and Adolescents: IV: 0.075 to 0.15 mg/kg; repeat as needed.

Continuous IV infusion: Infants, Children, and Adolescents: IV infusion: 7 to 12 mcg/kg/minute (0.42 to 0.72 mg/kg/hour); higher doses have been reported with prolonged infusions (Ref).

Rapid sequence intubation

Rapid sequence intubation: Limited data available:

Infants, Children, and Adolescents: IV: Usual: 1 mg/kg; range: 0.6 to 1.2 mg/kg. Note: In children and adolescents, some studies found lower doses of 0.6 mg/kg resulted in prolonged time to onset, shortened duration of neuromuscular blockade and less favorable intubating conditions (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

Infants, Children, and Adolescents: No dosage adjustment necessary; duration of neuromuscular blockade may vary in patients with kidney impairment.

Dosing: Hepatic Impairment: Pediatric

Infants, Children, and Adolescents: There are no dosage adjustments provided in the manufacturer's labeling; use with caution in patients with clinically significant liver impairment. Due to increased volume of distribution in patients with liver disease, neuromuscular blockade may be prolonged; dosage reductions may be necessary. Adults with ascites requiring rapid sequence intubation may need higher initial doses to achieve adequate neuromuscular blockade.

Adverse Reactions

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

Contraindications

Hypersensitivity (eg, anaphylaxis) to rocuronium, other neuromuscular-blocking agents, or any component of the formulation

Warnings/Precautions

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.

Dosage Forms: US

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)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (Rocuronium Bromide Intravenous)

50 mg/5 mL (per mL): $0.37 - $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.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Intravenous:

Generic: 10 mg/mL ([DSC])

Solution, Intravenous, as bromide:

Generic: 50 mg/5 mL (5 mL)

Administration: Adult

IV: May be administered as a bolus injection (undiluted) or via a continuous infusion.

Administration: Pediatric

Parenteral:

IM: Administer undiluted by rapid IM injection into the deltoid muscle (Ref).

IV: Administer undiluted by rapid IV injection.

Continuous IV infusion: Administer undiluted or further diluted in a compatible diluent using an infusion pump (Ref).

Use: Labeled Indications

Endotracheal intubation: To facilitate endotracheal intubation and rapid sequence intubation.

Mechanically ventilated patients in the ICU, neuromuscular blockade: Provide skeletal muscle relaxation during mechanical ventilation in ICU patients.

Neuromuscular blockade during general anesthesia: As an adjunct to general anesthesia to provide skeletal muscle relaxation during surgery.

Note: Neuromuscular blockade does not provide pain control, sedation, or amnestic effects. Ensure adequate pain control and sedation prior to and during administration of neuromuscular blockade (SCCM [Murray 2016]).

Medication Safety Issues
Sound-alike/look-alike issues:

Rocuronium may be confused with Romazicon

Zemuron may be confused with Remeron, Zemplar.

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes (neuromuscular blocker agent) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Acute Care Settings).

Other safety concerns:

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.

Metabolism/Transport Effects

None known.

Drug Interactions

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 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). Specifically, this effect is observed with chronic phenytoin administration. Fosphenytoin-Phenytoin may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Specifically, this effects is observed with acute/short term phenytoin administration. 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

Pregnancy Considerations

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.

Breastfeeding Considerations

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).

Monitoring Parameters

Vital signs (heart rate, blood pressure, respiratory rate); degree of muscle paralysis (eg, presence of spontaneous movement, ventilator asynchrony, shivering, and use 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.

Mechanism of Action

Blocks acetylcholine from binding to receptors on motor endplate inhibiting depolarization

Pharmacokinetics (Adult Data Unless Noted)

Onset of action:

Infants ≥3 months and Children: 30 seconds to 1 minute.

Adults: Good intubation conditions within 45 seconds to 3 minutes (dose dependent); maximum neuromuscular blockade within 4 minutes (Engstrom 2023, manufacturer’s labeling).

Duration:

Infants: 3 to 12 months: 40 minutes.

Children: 1 to 12 years: 26 to 30 minutes.

Adults: ~20 to 120 minutes (dose dependent, increases with higher doses and inhalational anesthetic agents); hypothermia may prolong the duration of action (Engstrom 2023, manufacturer’s labeling).

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 (up to 33% excreted in the urine) (Price 2012; Robertson 2005).

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.

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Altered kidney function: Clearance is reduced by 39% in kidney failure, and recovery time (as measured by the time it takes for the train of four ratio to return to 0.7) is prolonged from 54 minutes in control patients to 88 minutes in patients with severe kidney impairment. Patients with kidney failure have higher interindividual variation in (and hence less predictable) durations of response compared to patients with normal kidney function (Robertson 2005).

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.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Rocuron;
  • (AR) Argentina: Fada rocuronio | Rocunovag | Rocuronio kabi;
  • (AT) Austria: Esmeron | Rocuroniumbromid B. Braun | Rocuroniumbromid hameln | Rocuroniumbromid hikma | Rocuroniumbromid Kabi | Rocuroniumbromid Sandoz;
  • (AU) Australia: Baxter rocuronium | DBL Rocuronium Bromide | Rocon | Rocuronium kabi | Rocuronium mylan | Rocuronium Sandoz;
  • (BD) Bangladesh: Rocuron;
  • (BE) Belgium: Rocuronium B. Braun | Rocuronium Sandoz;
  • (BG) Bulgaria: Rocuronium bromide fresenius Kabi;
  • (BR) Brazil: Brometo de rocuronio | Brometo de rocuronio hikma | Misck | Rocuron | Unirez;
  • (CH) Switzerland: Esmeron | Rocuronium fresenius | Rocuronium labatec | Rocuronium mepha | Rocuronium Sandoz;
  • (CI) Côte d'Ivoire: Esmeron;
  • (CL) Chile: Esmeron;
  • (CN) China: Esmeron;
  • (CO) Colombia: Bromuro de rocuronio | Bromuro rocuronio | Lufcuren | Rocuronio | Rocuronio bromuro;
  • (CZ) Czech Republic: Esmeron | Rocuronium B. Braun | Rocuronium bromide Hameln | Rocuronium fresenius kabi;
  • (DE) Germany: Esmeron | Rocuronium inresa | Rocuroniumbromid B.Braun | Rocuroniumbromid hameln | Rocuroniumbromid Hexal | Rocuroniumbromid hikma | Rocuroniumbromid Hospira | Rocuroniumbromid Kabi | Rocuroniumbromid Pfizer | Rocuroniumbromid-ratiopharm;
  • (DO) Dominican Republic: Esmeron | Rocuron;
  • (EC) Ecuador: Bromuro de rocuronio | Esmeron | Flacidine | Rocuron | Rocuronio | Rocuronio bromuro;
  • (EE) Estonia: Esmeron | Myocron | Rocuronium | Rocuronium bromide fresenius Kabi | Rocuronium bromide grindeks;
  • (EG) Egypt: Esmeron | Rocubromide | Rocuroniumbromid hameln | Rocuthesia;
  • (ES) Spain: Esmeron | Rocuronio Braun | Rocuronio hikma | Rocuronio hospira | Rocuronio kabi;
  • (ET) Ethiopia: Rocutroy;
  • (FI) Finland: Esmeron | Rocuronium B Brau | Rocuronium fresenius kabi | Rocuronium hameln | Rocuronium hospira;
  • (FR) France: Rocuronium B Brau | Rocuronium Hikma | Rocuronium hospira | Rocuronium kabi | Rocuronium kalceks | Rocuronium mylan | Rocuronium noridem;
  • (GB) United Kingdom: Esmeron | Rocuronium | Rocuronium Bromid Kabi;
  • (GR) Greece: Esmeron;
  • (HU) Hungary: Esmeron;
  • (ID) Indonesia: Esmeron | Kabiroc | Noveron | Rocum | Rocuronium;
  • (IE) Ireland: Esmeron;
  • (IN) India: Esmeron | Kabiroc | Rocsur | Rocunium | Rocutroy;
  • (IT) Italy: Esmeron | Rocuronio b.braun | Rocuronio bromuro SALF | Rocuronio hikma | Rocuronio hospira | Rocuronio kabi | Rocuronio san | Rocuronio Sandoz;
  • (JO) Jordan: Esmeron | Rimexa | Rucoron;
  • (KE) Kenya: Rocuronium;
  • (KR) Korea, Republic of: Curoni | Dongkook rocuronium bromide | Esmeron | Kabi rocuronium | Rocaron | Rocnium | Rocumeron | Rocunium | Rocurin | Rocuron | Romeron;
  • (LB) Lebanon: Esmeron;
  • (LT) Lithuania: Esmeron | Rocurocel | Rocuronium bromide kalceks | Rocuronium hameln | Rocuronium Hikma | Roqurum;
  • (LV) Latvia: Esmeron | Rocuronium bromide kalceks;
  • (MA) Morocco: Esmeron;
  • (MX) Mexico: Curionialis | Desproxyl | Esmeron | Lufcuren | Mirontrex | Neolblock | Pablax | Robulvar | Rocuronio | Somtus;
  • (MY) Malaysia: Esmeron | Rocsur | Rocuronium hameln | Rocuronium kabi;
  • (NL) Netherlands: Esmeron | Rocuroniumbromide erc | Rocuroniumbromide eureco pharma | Rocuroniumbromide Fresenius Kabi | Rocuroniumbromide hospira | Rocuroniumbromide ratiopharm | Rocuroniumbromide Sandoz;
  • (NO) Norway: Esmeron;
  • (NZ) New Zealand: Arrow rocuronium | Esmeron;
  • (PE) Peru: Bromuro rocuronio | Esmeron | Flacidine | Rocsur | Rocubron | Rocuronio | Rocuronio bromuro | Romeron;
  • (PH) Philippines: Esmeron | Kabiroc | Rocuron | Rocuronium;
  • (PK) Pakistan: Esmeron;
  • (PL) Poland: Esmeron | Rocuronium Braun | Rocuronium bromide Hameln | Rocuronium kabi | Rocuronium kalceks | Roqurum;
  • (PR) Puerto Rico: Rocuronium | Zemuron;
  • (PT) Portugal: Brometo de rocuronio hikma | Esmeron;
  • (QA) Qatar: Esmeron;
  • (RU) Russian Federation: Esmeron | Kruaron | Rocuronium | Rocuronium binergy | Rocuronium kabi;
  • (SA) Saudi Arabia: Esmeron | Rocuronium | Rucoron;
  • (SE) Sweden: Esmeron | Rocuronium B. Braun | Rocuronium fresenius kabi | Rocuronium hameln | Rocuronium hospira;
  • (SG) Singapore: Esmeron;
  • (SI) Slovenia: Esmeron;
  • (SK) Slovakia: Esmeron | Rocuronium B.Braun | Rocuronium bromide Hameln | Rocuronium bromide kalceks | Rocuronium fresenius kabi | Rocuxant;
  • (TH) Thailand: Esmeron;
  • (TN) Tunisia: Esmeron;
  • (TR) Turkey: Antarin | Curon | Esmeron | Jecron | Muscuron | Myocron | Rocurex;
  • (TW) Taiwan: Esmeron | Rocurin | Rocuronium | Rocuronium hameln;
  • (UA) Ukraine: Esmeron | Rocuronio kabi;
  • (UG) Uganda: Rocutroy;
  • (UY) Uruguay: Rocuron | Zemuron;
  • (VE) Venezuela, Bolivarian Republic of: Rocur | Rocuronio bromuro;
  • (ZA) South Africa: Adco rocuronium | Antarin | Erunom | Esmeron | Rocuronium fresenius | Trakeze
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