Zemuron

Muscle Relaxants, Peripherally Acting

Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
Accidental administration of neuromuscular blocking agents can be fatal. Store rocuronium with the cap and ferrule intact, in a manner that minimizes the possibility of selecting the wrong product.[42031]
Updates for coronavirus disease 2019 (COVID-19): The FDA is allowing rocuronium 50 mg/5 mL and 100 mg/10 mL to be used beyond the labeled in-use time to help ensure access during COVID-related drug shortages. This period should be as short as possible, and for a maximum of 2 hours at room temperature or 4 hours when refrigerated. In-use time is defined as the maximum amount of time allowed to elapse between penetration of a closed-container system or after reconstitution of a lyophilized drug before patient administration.[65833]

Only experienced clinicians, familiar with the use of neuromuscular blocking drugs, should administer or supervise the use of rocuronium. Adequacy of respiration must be assured through assisted or controlled ventilation.
To avoid distress to the patient, administer rocuronium only after unconsciousness has been induced. Adequate amnesia, sedation, and analgesia should accompany neuromuscular blockade.
Do not mix rocuronium with alkaline solutions (e.g., barbiturate solutions such as thiopental) in the same syringe or administer simultaneously during IV infusion through the same needle or through the same IV line; rocuronium has an acidic pH.
If extravasation occurs, stop the injection or infusion and restart in another vein.[42031]
 
Intermittent IV Injection
No dilution necessary.
Administer by direct IV injection over 5 to 10 seconds.[42031]
Continuous IV Infusion
Dilute with 0.9% Sodium Chloride Injection, 5% Dextrose Injection, 5% Dextrose and 0.9% Sodium Chloride Injection, Lactated Ringer's Injection, or Sterile Water for Injection to a concentration up to 5 mg/mL.[42031]
ASHP Recommended Standard Concentrations for Adult Continuous Infusions: 10 mg/mL (undiluted).[64020]
Infuse at a rate based on patient response and requirements.
A peripheral nerve stimulator is recommended to monitor rocuronium's effects. Target response is typically 1 to 2 twitches. Incorrect electrode placement, direct stimulation of muscle due to large electrode size, acute illness, capillary leak, and edema may affect an appropriate assessment. Monitor visual and tactile stimulation on muscle movement as well as heart rate, blood pressure, and mechanical ventilator status during administration.[42031] [52441]
Storage: Diluted solutions may be stored at room temperature for up to 24 hours in plastic bags, glass bottles, and plastic syringe pumps.[42031]

NOTE: Rocuronium is not FDA-approved for intramuscular administration.
Not recommended. In children 3 months to 5 years, a rapid single bolus into the deltoid muscle has been studied; adequate intubating conditions were not consistently obtained in studies.

bronchospasm / Rapid / 0-1.0
angioedema / Rapid / Incidence not known
anaphylactoid reactions / Rapid / Incidence not known
malignant hyperthermia / Rapid / Incidence not known
apnea / Delayed / Incidence not known
muscle paralysis / Delayed / Incidence not known
acute quadriplegic myopathy syndrome / Delayed / Incidence not known
thrombosis / Delayed / Incidence not known
keratitis / Delayed / Incidence not known
pulmonary hypertension / Delayed / Incidence not known

hypertension / Early / 0.1-2.0
hypotension / Rapid / 0.1-2.0
sinus tachycardia / Rapid / 0-1.4
wheezing / Rapid / 0-1.0
edema / Delayed / 0-1.0
QT prolongation / Rapid / Incidence not known
erythema / Early / Incidence not known
dyspnea / Early / Incidence not known
hypoxia / Early / Incidence not known
myopathy / Delayed / Incidence not known
respiratory depression / Rapid / Incidence not known
conjunctivitis / Delayed / Incidence not known
skin erosion / Delayed / Incidence not known
skin ulcer / Delayed / Incidence not known
tolerance / Delayed / Incidence not known

hiccups / Early / 0-1.0
pruritus / Rapid / 0-1.0
rash / Early / 0-1.0
nausea / Early / 0-1.0
vomiting / Early / 0-1.0
injection site reaction / Rapid / 0-1.0
urticaria / Rapid / Incidence not known
flushing / Rapid / Incidence not known
weakness / Early / Incidence not known
xerophthalmia / Early / Incidence not known
anxiety / Delayed / Incidence not known

Zemuron

Rx

Parenteral, intermediate-acting, nondepolarizing, neuromuscular blocking agent (NMBA)
Used for an adjunct to general anesthesia to facilitate both rapid-sequence and routine tracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation
Minimal histamine release

0.45 to 1.2 mg/kg/dose IV. Onset of intubating conditions is less than 2 minutes. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions. 

0.45 to 0.6 mg/kg/dose IV. Onset of intubating conditions is 60 to 75 seconds.[42031] A lower dose of 0.3 mg/kg IV has been used successfully in combination with inhalation anesthesia induction for surgery.[52549] Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[42031]

0.45 to 0.6 mg/kg/dose IV. Onset of intubating conditions is 1 to 2 minutes.[42031] [44872] [53140] [53151] The lower dose of 0.45 mg/kg results in significantly shorter recovery time compared to larger doses.[53151] Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[42031]

0.6 to 1.2 mg/kg/dose IV. Onset of intubating conditions is less than 2 minutes. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.6 to 1.2 mg/kg/dose IV. Usual dose: 1 mg/kg/dose. Onset of intubating conditions is 1 to 2 minutes.[44771] [52550] [64934] Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[42031]

0.45 to 1.2 mg/kg/dose IV. Onset of intubating conditions is 1 to 2 minutes.[44872] [53140] [53151] Specific recommendations for RSI are not available; doses are extrapolated from use in non-emergent situations. The lower dose of 0.45 mg/kg results in significantly shorter recovery time compared to larger doses.[53151] Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[42031]

0.6 to 1 mg/kg IV once, followed by 0.1 to 1 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.45 to 0.6 mg/kg IV once, followed by 0.075 to 0.6 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response. Children (3 to 11 years) generally have the largest dosage requirement. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.  

0.45 to 0.6 mg/kg IV once, followed by 0.075 to 0.6 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response. Neonates generally have a lower dosage requirement. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.6 to 1 mg/kg IV bolus, followed by 8 to 12 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Usual dosage range: 4 to 16 mcg/kg/minute. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.6 mg/kg IV bolus, followed by 5 to 10 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Children (3 to 11 years) generally have the largest dosage requirement. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.6 mg/kg IV bolus, followed by 5 to 10 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Neonates generally have a lower dosage requirement. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.45 to 1.2 mg/kg IV once, followed by 0.1 to 0.2 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.45 to 0.6 mg/kg IV once, followed by 0.075 to 0.15 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response. Children (3 to 11 years) generally have the largest dosage requirement. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[42031]

0.45 to 0.6 mg/kg IV once, followed by 0.075 to 0.15 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response. Neonates generally have a lower dosage requirement. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[42031]

0.45 to 1.2 mg/kg IV bolus, followed by 10 to 12 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Dosage range: 4 to 16 mcg/kg/minute. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.45 to 0.6 mg/kg IV bolus, followed by 7 to 12 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Children (3 to 11 years) generally have the largest dosage requirement. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[42031] 

0.45 to 0.6 mg/kg IV bolus, followed by 7 to 12 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Neonates generally have a lower dosage requirement. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[42031]

Limited data; 0.6 mg/kg/dose IV as needed.[56387] Guidelines suggest that neuromuscular blocking agents may be used to manage overt shivering in therapeutic hypothermia.

Limited data; 0.25 mg/kg IV bolus, followed by 0.25 mg/kg/hour continuous IV infusion or 0.6 mg/kg IV bolus, followed by 0.15 mg/kg/hour continuous IV infusion.[56387] [65372] Guidelines suggest that neuromuscular blocking agents may be used to manage overt shivering in therapeutic hypothermia.

†Indicates off-label use

Specific guidelines for dosage adjustments in patients with hepatic impairment are not available. Use rocuronium with caution in patients with clinically significant hepatic impairment; patients with hepatic disease may experience prolonged recovery time. In patients with ascites, an increased initial dosage may be required to achieve adequate neuromuscular blockade. Duration will be prolonged in these cases.[42031]

Specific guidelines for dosage adjustments in renal impairment are not available. Patients with renal failure may have a more variable duration of effect.

Acebutolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Amide local anesthetics: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Aminoglycosides: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Atorvastatin: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Benazepril: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Celecoxib: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Olmesartan: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Valsartan: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amphotericin B lipid complex (ABLC): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Amphotericin B liposomal (LAmB): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Amphotericin B: (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Atenolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Atenolol; Chlorthalidone: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Bacitracin: (Minor) Concomitant use of neuromuscular blockers and systemic bacitracin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Beta-blockers: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Betaxolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Bismuth Subcitrate Potassium; Metronidazole; Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bismuth Subsalicylate; Metronidazole; Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bisoprolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Bisoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Botulinum Toxins: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Brimonidine; Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Calcium Acetate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Famotidine; Magnesium Hydroxide: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Magnesium Hydroxide: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Magnesium Hydroxide; Simethicone: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Simethicone: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Chloride: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Gluconate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium; Vitamin D: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium-channel blockers: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Capreomycin: (Minor) Concomitant use of neuromuscular blockers and capreomycin may prolong neuromuscular blockade. A partial neuromuscular blockade was demonstrated after large intravenous doses of capreomycin.
Carbamazepine: (Moderate) Monitor for a more rapid recovery from neuromuscular blockade than expected during concurrent use of carbamazepine and rocuronium. When administering neuromuscular blockade via continuous infusion, infusion rate requirements may be higher. Chronic carbamazepine administration may cause neuromuscular blockade resistance.
Carbonic anhydrase inhibitors: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
Carteolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Carvedilol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Chromium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Clevidipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Colistimethate, Colistin, Polymyxin E: (Moderate) Use neuromuscular blockers and polymyxins with extreme caution. Concomitant use of neuromuscular blockers and polymyxins may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Colistin: (Moderate) Use neuromuscular blockers and polymyxins with extreme caution. Concomitant use of neuromuscular blockers and polymyxins may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Corticosteroids: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Cyclosporine: (Moderate) Concomitant use of neuromuscular blockers and cyclosporine may prolong neuromuscular blockade.
Demeclocycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Desflurane: (Moderate) Concomitant use of rocuronium and desflurane may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration. During maintenance of desflurane anesthesia, the rocuronium dose is likely to be reduced compared to that during nitrous oxide/opioid anesthesia. For endotracheal intubation, do not reduce the dose of rocuronium.
Dextromethorphan; Quinidine: (Moderate) Concomitant use of neuromuscular blockers and quinidine may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Diltiazem: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Donepezil: (Moderate) A higher rocuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as donepezil.
Donepezil; Memantine: (Moderate) A higher rocuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as donepezil.
Dorzolamide; Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Doxapram: (Minor) Doxapram may temporarily mask the residual effects of neuromuscular blockers.
Doxycycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Ephedrine: (Minor) Ephedrine may reduce the onset time of neuromuscular blockade when used for intubation with rocuronium if given simultaneously with anesthetic induction.
Ephedrine; Guaifenesin: (Minor) Ephedrine may reduce the onset time of neuromuscular blockade when used for intubation with rocuronium if given simultaneously with anesthetic induction.
Esmolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Ester local anesthetics: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Felodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Folic Acid, Vitamin B9: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Fosphenytoin: (Moderate) Concomitant use of neuromuscular blockers and fosphenytoin may increase resistance to the neuromuscular blockade action of neuromuscular blockers, resulting in shorter durations of neuromuscular blockade and higher infusion rate requirements. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Galantamine: (Moderate) A higher rocuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as galantamine.
Indapamide: (Moderate) Concomitant use of neuromuscular blockers and indapamide may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Irinotecan Liposomal: (Moderate) Irinotecan may antagonize the neuromuscular blocking effects of rocuronium due to anticholinesterase activity.
Irinotecan: (Moderate) Irinotecan may antagonize the neuromuscular blocking effects of rocuronium due to anticholinesterase activity.
Isoflurane: (Major) Reduce the initial rocuronium dose if rocuronium is first administered after establishment of steady-state isoflurane anesthesia. Isoflurane may prolong the duration of action of initial and maintenance doses of rocuronium and decrease the average rocuronium infusion requirement by 40% compared to opioid/nitrous oxide/oxygen anesthesia. The clinical duration of initial doses of rocuronium 0.57 to 0.85 mg/kg under isoflurane anesthesia was increased by 23%. The duration of maintenance doses was affected to a greater extent, increasing by 30% to 50% under either isoflurane anesthesia. Under isoflurane anesthesia, the infusion rates are decreased by approximately 40% compared to opioid/nitrous oxide/oxygen anesthesia. The median spontaneous recovery time (from 25% to 75% of control T1, defined as 3 twitches of train-of-four) is prolonged by isoflurane (62% longer).
Isradipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Ketorolac: (Minor) There have been postmarketing reports of a possible interaction between ketorolac and nondepolarizing neuromuscular blockers, such as rocuronium, that resulted in apnea.
Labetalol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Levamlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Levobunolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Lincosamides: (Moderate) Use neuromuscular blockers and lincosamides with caution. Concomitant use of neuromuscular blockers and lincosamides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lithium: (Moderate) Concomitant use of neuromuscular blockers and lithium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Loop diuretics: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Lopinavir; Ritonavir: (Moderate) Monitor clinical effect and decrease the rocuronium dosage, if needed, if rocuronium is used concomitantly with ritonavir. Ritonavir may potentially decrease biliary excretion of rocuronium.
Magnesium: (Moderate) Concomitant use of neuromuscular blockers and magnesium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Metoprolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Metoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Minocycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Nadolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Nebivolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Nebivolol; Valsartan: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Neostigmine: (Moderate) A higher rocuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as neostigmine. Intravenous neostigmine is indicated for reversal of the effects of nondepolarizing neuromuscular blockers, such as rocuronium.
Neostigmine; Glycopyrrolate: (Moderate) A higher rocuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as neostigmine. Intravenous neostigmine is indicated for reversal of the effects of nondepolarizing neuromuscular blockers, such as rocuronium.
Nicardipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Nifedipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Nimodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Nirmatrelvir; Ritonavir: (Moderate) Monitor clinical effect and decrease the rocuronium dosage, if needed, if rocuronium is used concomitantly with ritonavir. Ritonavir may potentially decrease biliary excretion of rocuronium.
Nisoldipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Omadacycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Perindopril; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Phenytoin: (Moderate) Concomitant use of neuromuscular blockers and phenytoin may increase resistance to the neuromuscular blockade action of neuromuscular blockers, resulting in shorter durations of neuromuscular blockade and higher infusion rate requirements. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Physostigmine: (Moderate) A higher rocuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as physostigmine.
Pindolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Piperacillin; Tazobactam: (Moderate) Concomitant use of rocuronium and piperacillin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Polymyxin B: (Major) Avoid concomitant use of systemic polymyxin B and neuromuscular blockers due to the risk of respiratory depression. The neurotoxicity of polymyxin B may can result in neuromuscular blockade, especially when given soon after neuromuscular blockers. If signs of respiratory paralysis appear, assist respiration and discontinue drug therapy.
Procainamide: (Moderate) A lower neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant procainamide use due to procainamide effects on reducing acetylcholine release. Concomitant use of neuromuscular blockers and procainamide may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Propranolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Propranolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Pyridostigmine: (Moderate) A higher rocuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as pyridostigmine. Intravenous pyridostigmine is indicated for reversal of the effects of nondepolarizing neuromuscular blockers, such as rocuronium.
Pyridoxine, Vitamin B6: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Quinidine: (Moderate) Concomitant use of neuromuscular blockers and quinidine may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Quinine: (Major) Avoid concomitant use of neuromuscular blockers and quinine. Quinine may enhance the action of neuromuscular blockers. In 1 patient who received a neuromuscular blocker during an operative procedure, subsequent administration of quinine 1,800 mg 3 hours later resulted in respiratory depression.
Ranitidine: (Moderate) Ranitidine may cause resistance to rocuronium-induced neuromuscular blockade, due to pharmacodynamic alterations at the acetylcholine receptor. In vitro studies demonstrate that therapeutic serum concentrations of ranitidine inhibit acetylcholinesterase, thus increasing the amount of acetylcholine available to compete at the neuromuscular junction and reverse the neuromuscular blockade. The inhibition of acetylcholinesterase is likely dose-related. Resistance to nondepolarizing neuromuscular blockers was reported occasionally with intravenous ranitidine dosages that were slightly higher than those given clinically, but not frequently with oral therapy.
Ritonavir: (Moderate) Monitor clinical effect and decrease the rocuronium dosage, if needed, if rocuronium is used concomitantly with ritonavir. Ritonavir may potentially decrease biliary excretion of rocuronium.
Rivastigmine: (Moderate) A higher rocuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as rivastigmine.
Sarecycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Sevoflurane: (Moderate) Concomitant use of rocuronium and sevoflurane may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration. During maintenance of sevoflurane anesthesia, the rocuronium dose is likely to be reduced compared to that during nitrous oxide/opioid anesthesia. For endotracheal intubation, do not reduce the dose of rocuronium.
Sotalol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Stiripentol: (Moderate) Monitor for excessive sedation and somnolence during coadministration of stiripentol and rocuronium. CNS depressants can potentiate the effects of stiripentol.
Succinylcholine: (Major) If succinylcholine is used before rocuronium, delay rocuronium administration until recovery from succinylcholine-induced neuromuscular blockade begins. The median duration of action of rocuronium 0.6 mg/kg administered after succinylcholine 1 mg/kg when T1 (defined as 3 twitches of train-of-four) returned to 75% of control was 36 minutes (range: 14 to 57, n = 12) vs. 28 minutes (range: 17 to 51, n = 12) without succinylcholine.
Telmisartan; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Tetracyclines: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Theophylline, Aminophylline: (Moderate) A higher neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant aminophylline use. Aminophylline may antagonize neuromuscular blocking effects, possibly due to phosphodiesterase inhibition. (Moderate) A higher neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant theophylline use. Theophylline may antagonize neuromuscular blocking effects, possibly due to phosphodiesterase inhibition.
Thiazide diuretics: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Trandolapril; Verapamil: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Vancomycin: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Verapamil: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.

Rocuronium/Rocuronium Bromide/Zemuron Intravenous Inj Sol: 1mL, 10mg

Specific maximum dosage information is not available. Dosage must be individualized based on clinical response.

Muscle contraction is initiated by an action potential traveling from the central nervous system to the nerve terminal. At the nerve terminal, the action potential causes an influx of calcium, initiating the release of acetylcholine (ACh) into the synaptic cleft. ACh binds to ACh receptors on the muscle fiber's motor end-plate causing a conformational change that briefly opens sodium ion channels. When an adequate number of ACh receptors are activated, membrane potential decreases and voltage-dependent sodium ion channels of adjacent muscle membranes activate, transmitting the action potential throughout the muscle fiber and resulting in muscle contraction.[52452] Nondepolarizing neuromuscular blocking agents (NMBAs) such as rocuronium produce skeletal muscle paralysis by competing with ACh for cholinergic receptor sites at the motor end-plate.[52486] Neuromuscular blockade progresses in a predictable order, beginning with muscles associated with fine movements (e.g., eyes, face, and neck), followed by muscles of the limbs, chest, and abdomen and, finally, the diaphragm. Larger doses increase the chance of respiratory depression associated with relaxation of the intercostal muscles and the diaphragm. Muscle tone returns in the reverse order.[52503]
 
Rocuronium is a monoquaternary aminosteroid. It is an analog of vecuronium and was developed in an attempt to provide an agent with a more rapid onset of action to rival the polarizing agent succinylcholine. It is 10% to 15% as potent as its parent compound. NMBAs do not have the same effects on every muscle group and the onset of laryngeal adductor paralysis is slower with rocuronium compared to succinylcholine.[52557] In addition to its therapeutic actions, rocuronium can cause an increase in heart rate, but this is minimal even at large doses. Rocuronium produces little histamine release and no ganglion blockade; therefore, hypotension and bronchospasm are not associated with its use.[52452] [52557]

Rocuronium is administered intravenously; although not FDA-approved, the intramuscular route has been studied in pediatric patients. Rocuronium is distributed into the extracellular space and not into fat reserves. Protein binding is about 30%. Tissue redistribution accounts for about 80% of the initial dose administered. As tissue compartments fill with continued dosing (4 to 8 hours), less drug is redistributed away from the site of action, and the infusion rate to maintain neuromuscular blockade falls to about 20% of the initial infusion rate. The use of a loading dose and a smaller infusion rate reduces the need for dosage adjustment. Metabolism of rocuronium occurs in the liver. Rarely, the metabolite 17-desacetyl-rocuronium has been detected in human plasma or urine. In animal models, this metabolite is one-twentieth as potent as the parent compound. Data suggest pharmacokinetic parameters are linearly proportional to body weight. The terminal half-life decreases with increasing age from 1.1 hours in neonates to 0.7 to 0.8 hours in older children and adolescents. In comparison, the terminal half-life in healthy adults is approximately 1.4 to 2.4 hours.[42031] [52452]
 
Affected cytochrome P450 isoenzymes and drug transporters: CYP3A4
Based on in vitro data, rocuronium is primarily metabolized by CYP3A4.[65228] [65229]

Onset time and clinical duration vary with dose, age, and anesthetic technique. After IV administration, plasma concentrations follow a 3-compartment open model; the half-life is 1 to 2 minutes during the rapid distribution phase and 14 to 18 minutes during the slower distribution phase. Larger doses decrease time to maximum effect and prolong the duration of action. In general, maximum neuromuscular effect is seen within 1 to 3 minutes in adults. Clinical duration is 22 to 67 minutes after a single bolus dose. In general, spontaneous recovery and reversal of neuromuscular blockade after rocuronium infusion discontinuation can be expected to be comparable to that after similar total exposure to single bolus doses.[42031]

Reported bioavailability after IM administration (deltoid muscle) of 14 infants and children (3 months to 5 years) was 82.6% Time to adequate tracheal intubation has varied among studies but is consistently longer than after IV rocuronium and IM succinylcholine administration. In a pilot study of infants and children (n = 29) anesthetized with nitrous oxide and halothane, rocuronium 1 mg/kg IM in infants and 1.8 mg/kg IM in children permitted tracheal intubation at 2.5 to 3 minutes and produced complete paralysis (100% twitch depression) in 7.4 minutes in infants and 6.3 minutes in children. A multicenter, randomized study of infants and children (n = 38, 3 months to 12 years) specifically designed to confirm those results reported inadequate intubating conditions at 3.5 to 4 minutes, with complete paralysis (at least 98% twitch depression) in 7.4 minutes in infants and 8.9 minutes in children. Simulations based on pharmacokinetic parameters suggest a median Tmax of 13 minutes (range: 9 to 19.8 minutes). In infants and children, 25% recovery occurred in 79 minutes and 86 minutes, respectively.

There are limited data regarding the use of rocuronium during breast-feeding. Due to poor oral absorption, poor lipid solubility, and short duration of action, it is not likely that rocuronium would reach the infant's bloodstream. No adverse effects, including dizziness and drowsiness, occurred in 4 infants of breast-feeding mothers who underwent various urgent surgeries during which rocuronium was used to facilitate intubation. Breast-feeding resumed 90 minutes to 5 hours after anesthesia.[46961] [63111] [63112]