neuromuscular blocker

Rocuronium

Zemuron

Route: IV
Onset: 60–90 seconds (at 1.2 mg/kg) vs. 45 seconds for succinylcholine
Duration: 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)

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

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

All Drugs

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

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