Zemuron

rocuronium

(roe-kyoor-own-ee-um) ,

Zemuron

(trade name)

Classification

Therapeutic: neuromuscular blocking agents nondepolarizing
Pregnancy Category: C

Indications

Induction of skeletal muscle paralysis and facilitation of intubation after induction of anesthesia in surgical procedures.Facilitation of compliance during mechanical ventilation.

Action

Prevents neuromuscular transmission by blocking the effect of acetylcholine at the myoneural junction. Has no analgesic or anxiolytic properties

Therapeutic effects

Skeletal muscle paralysis.

Pharmacokinetics

Absorption: Following IV administration, absorption is essentially complete.
Distribution: Rapidly distributes into extracellular space.
Metabolism and Excretion: Mostly metabolized and eliminated by the liver.
Half-life: Infants 3–12 mo: 0.8–1.8 hr; Children 1–3 yr: 0.4–1.8 hr; Children 3–8 yr: 0.5–1.1 hr; Adults: 1.4–2.4 hr (↑ to 4.3 hr in hepatic impairment and 2.4 hr in renal impairment)

Time/action profile

ROUTEONSETPEAKDURATION
IV1 min0.5–1 min (peds) 1–3.7 min (adults)26–40 min (peds) 31 min (adults)*
*Following 0.6 mg/kg dose in adult patients.

Contraindications/Precautions

Contraindicated in: Hypersensitivity;
Use Cautiously in: Dehydration or electrolyte abnormalities (should be corrected); Fractures or muscle spasm; Hyperthermia (↑ duration/intensity of paralysis); Significant hepatic impairment; Shock; Extensive burns (may be more resistant to effects); Low plasma pseudocholinesterase levels (may be seen in association with anemia, dehydration, cholinesterase inhibitors/insecticides, severe liver disease, pregnancy, or hereditary predisposition); Obese patients; Obstetric / Lactation: Safety not established (use only if benefit outweighs potential risk to fetus) Pediatric: Children <3 mo (safety and effectiveness not established)
Exercise Extreme Caution in: Neuromuscular diseases such as myasthenia gravis (small test dose may be used to assess response).

Adverse Reactions/Side Effects

Respiratory

  • bronchospasm

Dermatologic

  • rash

Miscellaneous

  • allergic reactions including anaphylaxis (life-threatening)

Interactions

Drug-Drug interaction

Intensity and duration of paralysis may be prolonged by pretreatment with succinylcholine, general anesthesia (inhalation), aminoglycosides, vancomycin, tetracyclines, polymyxin B, colistin, clindamycin, lidocaine, and other local anesthetics, lithium, quinidine, procainamide, beta-adrenergic blocking agents, potassium-losing diuretics, or magnesium.Higher infusion rates may be required and duration of action may be shortened in patients receiving long-term carbamazepine or phenytoin.May be associated with QTc interval prolongation when administered with general anesthesia.

Route/Dosage

Intravenous (Adults) Rapid sequence tracheal intubation—0.6–1.2 mg/kg; Maintenance dosing—0.1–0.2 mg/kg, repeat doses as needed; Continuous infusion—10–12 mcg/kg/min (range 4–16 mcg/kg/min).
Intravenous (Children ≥3 mo) Intubation dose—0.6 mg/kg; Maintenance dose— 0.075–0.125 mg/kg; Continuous infusion—12 mcg/kg/min.

Availability (generic available)

Solution for injection: 10 mg/ml

Nursing implications

Nursing assessment

  • Assess respiratory status continuously throughout therapy with neuromuscular blocking agents. These medications should be used only to facilitate intubation or in patients already intubated.
  • Neuromuscular response should be monitored with a peripheral nerve stimulator intraoperatively. Paralysis is initially selective and usually occurs sequentially in the following muscles: levator muscles of eyelids, muscles of mastication, limb muscles, abdominal muscles, muscles of the glottis, intercostal muscles, and the diaphragm. Recovery of muscle function usually occurs in reverse order.
  • Monitor ECG, heart rate, and BP throughout administration.
  • Observe the patient for residual muscle weakness and respiratory distress during the recovery period.
  • Monitor infusion site frequently. If signs of tissue irritation or extravasation occur, discontinue and restart in another vein.
  • If overdose occurs, use peripheral nerve stimulator to determine the degree of neuromuscular blockade. Maintain airway patency and ventilation until recovery of normal respirations occurs.
    • Administration of anticholinesterase agents (neostigmine, pyridostigmine) may be used to antagonize the action of neuromuscular blocking agents once the patient has demonstrated some spontaneous recovery from neuromuscular block. Atropine is usually administered prior to or concurrently with anticholinesterase agents to counteract the muscarinic effects.
    • Administration of fluids and vasopressors may be necessary to treat severe hypotension or shock.

Potential Nursing Diagnoses

Ineffective breathing pattern (Indications)
Impaired verbal communication (Side Effects)
Fear (Side Effects)

Implementation

  • high alert: Unplanned administration of a neuromuscular blocking agent instead of administration of the intended medication or administration of a neuromuscular blocking agent in the absence of ventilatory support has resulted in serious harm and death. Confusing similarities in packaging and insufficiently controlled access to these medications are often implicated in these medication errors.
  • Dose is titrated to patient response.
    • Neuromuscular blocking agents have no effect on consciousness or pain threshold. Adequate anesthesia/analgesia should always be used when neuromuscular blocking agents are used as an adjunct to surgical procedures or when painful procedures are performed. Benzodiazepines and/or analgesics should be administered concurrently when prolonged neuromuscular blocker therapy is used for ventilator patients, because patient is awake and able to feel all sensations.
    • If eyes remain open throughout prolonged administration, protect corneas with artificial tears.
    • Store rocuronium in refrigerator.
  • Intravenous Administration
  • Administer undiluted.
  • Rate: Titrate according to patient response.
  • Continuous Infusion: Diluent: 0.9% NaCl, sterile water for injection, D5W, LR injection, and D5/0.9% NaCl for infusion. Solution is stable for 24 hr at room temperature. Concentration: 0.5–1 mg/mL.
  • Rate: Infusion rates of 0.004–0.016 mg/kg/min have been used. Rate of infusion should be titrated according to patient's twitch response as monitored with a peripheral nerve stimulator.
  • Y-Site Compatibility: acyclovir, alemtuzumab, alfentanil, amikacin, aminocaproic acid, aminophylline, amiodarone, ampicillin, ampicillin/sulbactam, anidulafungin, argatroban, azithromycin, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, carboplatin, carmustine, caspofungin, cefepime, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, chlorpromazine, ciprofloxacin, clindamycin, cyclophosphamide, cytarabine, daptomycin, dexmedetomidine, dexrazoxane, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel, dolasetron, dopamine, doxycycline, droperidol, enalaprilat, ephedrine, epinephrine, epirubicin, eptifibatide, ertapenem, esmolol, etoposide, etoposide phosphate, fenoldopam, fentanyl, fluconazole, fludarabine, foscarnet, fosphenytoin, ganciclovir, gemcitabine, gentamicin, granisetron, haloperidol, heparin, hydrocortisone sodium phosphate, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, irinotecan, isoproterenol, labetalol, levofloxacin, levorphanol, lidocaine, linezolid, magnesium hydroxide, mannitol, mechlorethamine, meperidine, meropenem, methotrexate, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, mitoxantrone, morphine, moxifloxacin, mycophenolate, nalbuphine, naloxone, nesiritide, nicardipine, nitroglycerin, nitroprusside, octreotide, ondansetron, oxaliplatin, palonosetron, pamidronate, pemetrexed, pentamidine, pentobarbital, phenobarbital, phenylephrine, potassium acetate, potassium chloride, procainamide, prochlorperazine, promethazine, propranolol, quinupristin/dalfopristin, ranitidine, remifentanil, sodium acetate, sodium bicarbonate, sodium phosphates, sufentanil, tacrolimus, teniposide, theophylline, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, vasopressin, verapamil, vincristine, voriconazole, zidovudine, zolendronic acid
  • Y-Site Incompatibility: amphotericin B colloidal, amphotericin B lipid complex, azathioprine, cefoperazone, diazepam, furosemide, hydrocortisone sodium succinate, insulin, ketorolac, lorazepam, methohexital, methoprednisolone, micafungin, pantoprazole, phenytoin, piperacillin/tazobactam, potassium phosphates, thiopental

Patient/Family Teaching

  • Explain all procedures to patient receiving neuromuscular blocker therapy without general anesthesia, because consciousness is not affected by neuromuscular blocking agents alone.
  • Reassure patient that communication abilities will return as the medication wears off.

Evaluation/Desired Outcomes

  • Adequate suppression of the twitch response when tested with peripheral nerve stimulation and subsequent muscle paralysis.
  • Improved compliance during mechanical ventilation.
  • Diagnosis of myasthenia gravis.

Zemuron

a trademark for a nondepolarizing neuromuscular blocking agent (rocuronium bromide).
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It is recommended that clinicians administering neuromuscular blocking agents, such as ZEMURON, employ a peripheral nerve stimulator to monitor drug effect, need for additional doses, adequacy of spontaneous recovery or antagonism, and to decrease the complications of overdosage if additional doses are administered.
Severe anaphylactic reactions to neuromuscular blocking agents, including ZEMURON, have been reported.
As with other non-depolarizing neuromuscular blocking drugs, apparent tolerance to ZEMURON may develop during chronic administration in the ICU.
Because ZEMURON is always used with other agents, and the occurrence of malignant hyperthermia during anesthesia is possible even in the absence of known triggering agents, clinicians should be familiar with early signs, confirmatory diagnosis and treatment of malignant hyperthermia prior to the start of any anesthetic.
The overall analysis of ECG data in pediatric patients indicates that the concomitant use of ZEMURON with general anesthetic agents can prolong the QTc interval.
In these or other patients in whom potentiation of neuromuscular block or difficulty with reversal may be anticipated, a decrease from the recommended initial dose of ZEMURON should be considered.
When ZEMURON (rocuronium bromide) is administered to these patients, shorter durations of neuromuscular block may occur, and infusion rates may be higher due to the development of resistance to non-depolarizing muscular relaxants.
The product, the generic equivalent of Zemuron, is being marketed in 50-mg/5-mL and 100-mg/10-mL strengths.
Rocuronium Bromide Teva Parenteral Zemuron Injection,
4 billion in 2006 (based on the closing exchange rate on March 9, 2007), including such leading products as Follistim/ Puregon, a follicle-stimulating hormone for infertility; Esmeron/ Zemuron, a muscle relaxant; and NuvaRing and Implanon for contraception.