Pharm 101: Rocuronium

Class

Paralytic agent

Pharmacodynamics

• Non-depolarising steroid neuromuscular blocking agent used as a paralytic in rapid sequence induction
• At low doses, acts predominately as a competitive inhibitor of Acetylcholine at nicotinic receptors
• At higher doses, can enter the pore of the ion channel causing greater neuromuscular blockade

Pharmacokinetics

• Undergoes rapid distribution
• Highly ionised therefore small volume of distribution 0.1L/kg
• Onset of action: 45-60 seconds
• Intermediate acting: duration of action 20-35 minutes
• Metabolism: liver
• Elimination: liver (75-90%) and kidney

Clinical uses

• Rapid Sequence Induction (RSI)
  • Dose 1.2mg/kg (accepted range 0.9-1.2mg/kg)
• Clinical effects:
  • Initially motor weakness followed by skeletal muscles becoming flaccid and unexcitable to electrical stimulation
  • Larger muscles (e.g. abdominal, trunk, diaphragm) are more resistant to neuromuscular blockade and recover more rapidly than smaller muscles (e.g. facial, foot, hand)
  • Diaphragm is the last muscle to be paralysed

Sugammadex

• Sugammadex is a modified cyclodextrin antidote used for rapid reversal of rocuronium and vecuronium
• Binds tightly to rocuronium in a 1:1 ratio, and this complex is excreted unchanged in the urine
• This decreases free plasma concentration and establishes a concentration gradient for rocuronium to diffuse away from the neuromuscular junction back into circulation for further binding to free sugammadex
• Dosing varies for desired reversal effects:
  • 2mg/kg: reversal of shallow neuromuscular blockade
  • 4mg/kg: reversal of deeper blockade
  • 16mg/kg: immediate reversal following administration of single dose 1.2mg/kg rocuronium
• Adverse effects:
  • Anaphylaxis in 0.3% of patients receiving 16mg/kg dosage
  • Hypersensitivity reactions are common
  • Bradycardia (may progress rapidly to cardiac arrest)
  • Coagulopathy: 25% elevation of APTT and PT/INR values lasting up to one hour

Further Reading

• Nickson C. Does Roc rock? Does Sux suck?. LITFL
• Long N. Sugammadex. LITFL
• Reid C. More on Rocuronium (and Sugammadex) Resus.ME

Robert Buttner

MBBS FACEM DDU (Emergency) CCPU. Emergency Physician in Melbourne, Australia. Co-Ultrasound Lead for Emergency Medicine at The Alfred Hospital. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor of the LITFL ECG Library.