Rocuronium for Tracheal Intubation

Laura S. Willets, Pharm.D.

Disclosures

Pediatr Pharm. 2000;6(10) 

In This Article

Dosing Recommendations and Monitoring

Rocuronium is available in 10 mg/mL vials containing 50 mg for injection. While intravenous administration is preferred[4,5,6,7,8,9,10,11,12,13,14], IM administration has also been reported. Intramuscular injection of rocuronium has been compared to intramuscular succinylcholine with conflicting results. Reynolds and colleagues found that deltoid injections of 1 mg/kg in infants and 1.8 mg/kg in children permitted intubation within 3 minutes with a time to recovery of greater than 60 minutes.[17] However, Kaplan found that after administering the same doses, adequate tracheal conditions were not reached until 7 minutes, and time to recovery was extended to 80 minutes.[18]

Recommendations for intravenous dosing in children have been derived from the results of several clinical studies. In infants and children, doses that have been evaluated range from 0.6 mg/kg to 1.2 mg/kg given as intravenous boluses in conjunction with either inhalational or intravenous anesthetics. These doses typically produce neuromuscular blockade within 60 seconds.[6,7,8,9,10,11] The usual dose for tracheal intubation in adults is 0.6 mg/kg. Continuous infusions of 0.01 to 0.012 mg/kg/min have been used to prolong paralysis after bolus dosing, once neuromuscular blockade has returned to 10% of control.[3] Tachyphylaxis can occur within 48 to 72 hours of continuous administration, requiring dosage adjustment to maintain the desired level of paralysis.[1]

Cardiovascular and respiratory status should be monitored in all patients receiving rocuronium. Heart rate and blood pressure may slightly increase while respiratory drive may decrease. Level of neuromuscular blockade should also be monitored. This can be achieved by electrically stimulating the ulnar nerve and assessing the train-of-four response or evaluating signs of muscle relaxation such as diaphragm response or decrease in jaw tone. It is important to remember that peripheral nerve stimulation may not reflect the response of the diaphragm or larynx.[1,5]

As with all nondepolarizing neuromuscular blockers, analgesics and sedatives must be administered during rocuronium use. If the patient is to be paralyzed for a prolonged period of time, other preventative measures should be taken. Deep vein thrombosis prophylaxis should be considered in older children. Artificial tears or ointment should be used to prevent corneal damage. Physical therapy and adequate nutrition should be used to prevent skin breakdown and muscle atrophy.[1,2,3,5]

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