What should the target train-of-four (TOF) response be for a patient receiving a Rocuronium (rocuronium bromide) infusion in the Intensive Care Unit (ICU)?

From the Guidelines

For a rocuronium infusion in an intubated ICU patient, the target should be 1-2 twitches on train-of-four (TOF) monitoring, as recommended by clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient 1. This level of neuromuscular blockade provides adequate muscle relaxation for mechanical ventilation while avoiding complete paralysis.

To achieve this, the following key points should be considered:

• Start with a loading dose of rocuronium, followed by a continuous infusion, titrating as needed based on TOF responses.
• Regular TOF monitoring every 1-2 hours is essential to prevent over-paralysis or under-dosing.
• Maintaining this moderate blockade reduces the risk of critical illness polyneuromyopathy and allows for faster recovery when the infusion is discontinued.
• Provide adequate sedation and analgesia alongside neuromuscular blockade, as paralyzed patients remain conscious and can experience pain and anxiety.
• Daily interruption of the infusion should be considered when clinically appropriate to assess neurological status and minimize complications from prolonged neuromuscular blockade.

The importance of monitoring and adjusting the degree of neuromuscular blockade is highlighted by the potential complications associated with prolonged recovery from neuromuscular blocking agents (NMBAs), including skeletal muscle weakness, myopathy, and myonecrosis 1. By targeting 1-2 twitches on TOF monitoring, healthcare providers can balance the need for effective muscle relaxation with the need to minimize these risks and optimize patient outcomes.

From the Research

Rocuronium Infusion in ICU

• The target for train of four (TOF) during rocuronium infusion in an intubated patient in ICU is to maintain one visible twitch of the TOF 2, 3, 4.
• This is achieved by adjusting the infusion rate of rocuronium to maintain a consistent level of neuromuscular blockade 3.
• The infusion requirements for rocuronium can vary significantly between patients, and monitoring of neuromuscular function is suggested to ensure optimal dosing 3.
• Studies have shown that continuous infusion of rocuronium can be used to provide effective neuromuscular blockade in ICU patients, with median infusion rates ranging from 0.3 to 2.2 mg.kg-1.hr-1 3.
• The use of TOF monitoring in conjunction with clinical tests is suitable for assessing neuromuscular recovery in patients receiving rocuronium 5.