Vecuronium Dosing for Ongoing Paralysis After Rocuronium Intubation
For ongoing paralysis after intubation with rocuronium, vecuronium should be administered at a dose of 0.1 mg/kg IV for routine paralysis, with adjustments based on neuromuscular monitoring. 1
Dosing Recommendations
Initial Dose
Maintenance Dosing
- Continuous infusion: 0.8-1.2 μg/kg/min 1
- Adjust rate based on desired degree of blockade and neuromuscular monitoring
- Intermittent bolus dosing: 0.01-0.015 mg/kg when clinical signs of recovery appear
Monitoring Recommendations
Neuromuscular monitoring is essential for proper dosing:
- Use Train-of-Four (TOF) stimulation at the adductor pollicis
- Maintain appropriate level of blockade based on clinical needs:
- For moderate blockade: Maintain 1-2 twitches on TOF
- For deep blockade: No response to TOF, monitor Post-Tetanic Count (PTC)
Special Considerations
Renal Impairment
- Reduce dosage by 30-50% in patients with renal failure 1
- Up to 35% of vecuronium is renally excreted, leading to prolonged effect in renal dysfunction
Hepatic Impairment
- Reduce dosage by 30-50% in patients with hepatic insufficiency 1
- Up to 50% of vecuronium is excreted in bile, requiring dose adjustment
Timing Considerations
- Vecuronium has a slower onset (2 minutes) compared to rocuronium 1
- Duration of action is approximately 45-90 minutes (dose-dependent) 1
Important Clinical Caveats
- Vecuronium provides only paralysis - it does not provide sedation, analgesia, or amnesia 1
- Always ensure adequate sedation and analgesia are maintained throughout paralysis to prevent awareness
- Patients receiving etomidate for intubation require additional sedation within 15 minutes to prevent awareness during ongoing paralysis 2
- Ventilatory support is mandatory during neuromuscular blockade 1
- Personnel skilled in airway management must be present whenever neuromuscular blocking agents are administered 1
Reversal of Neuromuscular Blockade
When paralysis is no longer needed:
- For moderate blockade (TOF count of 4): Neostigmine 0.04 mg/kg with atropine 0.02 mg/kg 1
- Allow 10-20 minutes for complete reversal (TOF ratio ≥ 0.9) 1
- If rocuronium was used and rapid reversal is needed, sugammadex is preferred 1
Remember that neuromuscular blocking agents like vecuronium require appropriate monitoring, dosing adjustments based on organ function, and concurrent administration of sedative and analgesic medications to ensure patient comfort and safety.