Rocuronium
Zemuron
neuromuscular blockerIVOnset: 60–90 seconds (at 1.2 mg/kg) vs. 45 seconds for succinylcholineDuration: 30–60 minutes (dose-dependent)
Mechanism of Action
Non-depolarizing neuromuscular blocking agent. Competitive antagonist at nicotinic acetylcholine receptors at neuromuscular junction. Blocks ACh binding → prevents end-plate depolarization → flaccid paralysis. No fasciculations.
Dosing
Adult
RSI: 1.2 mg/kg IV. Maintenance: 0.1–0.2 mg/kg q20–30 min or 10–12 mcg/kg/min infusion
Pediatric
Intubation: 0.6–1.2 mg/kg IV
Indications
- RSI (high-dose 1.2 mg/kg — alternative to succinylcholine)
- Facilitation of mechanical ventilation (continuous infusion)
- Surgical relaxation
- ARDS with refractory dyssynchrony (48-hour course)
Contraindications
- Hypersensitivity to rocuronium
- No reversal available (relative — sugammadex must be on hand)
Side Effects
- Prolonged paralysis (in liver failure — hepatic metabolism)
- Cardiovascular effects (minimal at therapeutic doses)
- Anaphylaxis (rare)
Monitoring Parameters
- Train-of-four (TOF) monitoring (goal: 1–2 twitches for adequate ICU paralysis)
- SpO2 and ETCO2
- Sedation and analgesia adequacy (patients MUST receive sedation/analgesia — paralysis does NOT sedate)
- Daily awakening/sedation vacation cannot be done while paralyzed
Drug Interactions
- Aminoglycosides (potentiate NMB — enhanced block)
- Inhalation anesthetics (potentiate NMB)
- Sugammadex (selective reversal agent — 16 mg/kg for immediate reversal)
- Furosemide (enhances block)
Clinical Pearls
- Preferred over succinylcholine when succinylcholine is contraindicated
- MUST ensure adequate sedation and analgesia — paralysis without sedation is inhumane
- Sugammadex reversal is rapid and complete (encapsulates rocuronium)
- Rocuronium accumulates in liver failure (prolonged block)
- ARDS: 48-hour cisatracurium or rocuronium infusion reduces 90-day mortality (ACURASYS trial — now debated by ROSE trial)
- No depolarization, no fasciculations, no hyperkalemia risk
Mnemonic
💡 ROCO: Rocuronium, Onset 60 sec, Competing with ACh, Offswitched by sUGammadex
NBRC High-Yield
- Non-depolarizing NMB — no fasciculations, no hyperkalemia
- RSI dose: 1.2 mg/kg (slightly slower onset than succinylcholine)
- Reversal: sugammadex (16 mg/kg for immediate reversal)
- TOF monitoring for ICU infusion (goal 1–2 twitches)
- Must provide adequate sedation and analgesia during paralysis
- Prolonged in hepatic failure