rocuronium
Brand: Zemuron
ISMP High Alert Prototype: succinylcholine
Drug Class: neuromuscular blocking agent (NMBA)
Drug Family: neuromuscular blocking agent
Subclass: non-depolarizing NMBA (aminosteroid)
Organ Systems: cnsmusculoskeletal
Mechanism of Action
Competitively blocks nicotinic receptors at the NMJ, preventing acetylcholine binding and producing flaccid muscle paralysis. At high doses (1.2 mg/kg), onset approaches that of succinylcholine. Fully reversible by sugammadex via encapsulation.
nicotinic acetylcholine receptor at neuromuscular junction (competitive antagonist)
Indications
- facilitation of endotracheal intubation
- intraoperative skeletal muscle relaxation
- RSI when succinylcholine is contraindicated (with sugammadex available)
Contraindications
- hypersensitivity to rocuronium
Adverse Effects
Common
- residual neuromuscular blockade
- injection site pain
Serious
- anaphylaxis (more common than other NMBAs)
- prolonged blockade
- respiratory failure from residual paralysis
Pharmacokinetics (ADME)
| Absorption | IV only |
| Distribution | protein binding ~30%; Vd ~0.2 L/kg |
| Metabolism | minimal hepatic; primarily excreted unchanged |
| Excretion | biliary (50%) and renal (30%) |
| Half-life | 1-2 hours |
| Onset | 60-90 seconds at 0.6 mg/kg; 60 seconds at 1.2 mg/kg |
| Peak | 1-3 minutes |
| Duration | 30-60 minutes at 0.6 mg/kg; 60-90 minutes at 1.2 mg/kg |
| Protein Binding | 30% |
| Vd | 0.2 L/kg |
Drug Interactions
| Drug / Agent | Mechanism | Severity |
|---|---|---|
| volatile anesthetics | potentiate neuromuscular blockade | moderate |
| aminoglycosides | potentiate neuromuscular blockade | moderate |
| sugammadex | complete reversal within 3 minutes at 16 mg/kg | beneficial |
Nursing Considerations
- Assess train-of-four (TOF) neuromuscular monitoring before reversal; reverse with neostigmine only when TOF ratio >0.25, or with sugammadex at any depth.
- Rocuronium is a known trigger of perioperative anaphylaxis; epinephrine and resuscitation must be immediately available.
- Residual neuromuscular blockade is a patient safety concern; confirm complete reversal (TOF ratio >0.9) before extubation.
- In cannot-intubate-cannot-oxygenate scenario after RSI with rocuronium, sugammadex 16 mg/kg reverses paralysis within 3 minutes.
Clinical Pearls
- Rocuronium at 1.2 mg/kg is used as alternative to succinylcholine for RSI when succinylcholine is contraindicated, requiring sugammadex availability for rapid reversal if intubation fails.
- Rocuronium has higher perioperative anaphylaxis rate than most NMBAs; the reaction may be cross-reactive across aminosteroid NMBAs via IgE-mediated sensitization.
Safety Profile
Pregnancy use-with-caution
Lactation use-with-caution
Renal Adjustment Not required
Hepatic Adjustment Required
TDM Not required
Concordance Terms
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