What are the effects of a rocuronium (a non-depolarizing neuromuscular blocking agent) overdose?

From the Guidelines

Rocuronium overdose should be treated immediately with sugammadex, which is the specific reversal agent for rocuronium, at a dose of at least 8.0 mg/kg IV as a single bolus, as recommended by the most recent guidelines 1.

Key Considerations

• The dose of sugammadex required for reversal is dependent on the degree of neuromuscular blockade, with deeper blockades requiring higher doses of sugammadex 2, 1.
• Monitoring of neuromuscular function using a peripheral nerve stimulator is crucial to adjust the sugammadex dose and to identify potential recurrence of neuromuscular blockade after reversal 2, 1.
• Anticholinesterases like neostigmine are ineffective for profound rocuronium blockade and should not be relied upon in overdose situations.
• Rocuronium overdose is dangerous because it causes complete paralysis, including respiratory muscles, while consciousness remains intact if adequate sedation is not maintained.

Patient Management

• If sugammadex is unavailable, supportive care with mechanical ventilation must be continued until the neuromuscular blockade resolves naturally, which may take several hours.
• Monitor vital signs, maintain adequate sedation, and assess neuromuscular function using a peripheral nerve stimulator.
• Hemodynamic support may be necessary as higher doses of rocuronium can cause histamine release and subsequent hypotension.
• Continue monitoring for recurrence of neuromuscular blockade, particularly in patients with renal impairment, as delayed elimination may occur 1.

Special Considerations

• The efficacy of sugammadex is decreased in elderly patients 1 and patients with severe renal failure (creatinine clearance < 30 mL/min) 1, especially in the case of deep blockade reversal.
• An inadequate dose of sugammadex may be the cause of the phenomenon of recurarisation, highlighting the importance of adjusting the sugammadex dose to the degree of blockade at the time of reversal 1.

From the FDA Drug Label

5. 1 Appropriate Administration and Monitoring Rocuronium bromide should be administered in carefully adjusted dosages by or under the supervision of experienced clinicians who are familiar with the drug's actions and the possible complications of its use The drug should not be administered unless facilities for intubation, mechanical ventilation, oxygen therapy, and an antagonist are immediately available It is recommended that clinicians administering neuromuscular blocking agents such as rocuronium bromide 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.

The effects of a rocuronium overdose include respiratory arrest and death due to paralysis. To minimize the risk of complications from overdosage, it is recommended to use a peripheral nerve stimulator to monitor drug effect and need for additional doses.

• Key considerations for managing a potential overdose include: + Immediate availability of facilities for intubation, mechanical ventilation, oxygen therapy, and an antagonist. + Careful monitoring of the patient's response to the drug. + Adjusting the dosage as needed to avoid overdosage. + Being aware of the potential for prolonged paralysis and/or skeletal muscle weakness, especially in patients who have chronically received neuromuscular blocking drugs in the ICU 3. It is essential to be cautious when administering rocuronium bromide, especially in patients with certain medical conditions or those taking other medications that may interact with the drug 4.

From the Research

Effects of Rocuronium Overdose

The effects of a rocuronium overdose are not directly addressed in the provided studies. However, the studies do discuss the reversal of rocuronium-induced neuromuscular blockade using sugammadex and neostigmine.

Reversal of Rocuronium-Induced Neuromuscular Blockade

• Sugammadex is a selective relaxant-binding agent that can rapidly reverse rocuronium-induced neuromuscular blockade, regardless of the depth of the block 5, 6, 7.
• Sugammadex is more effective and faster than neostigmine in reversing rocuronium-induced neuromuscular blockade 5, 6, 7.
• The time to achieve a train-of-four ratio of 0.9 is significantly shorter with sugammadex compared to neostigmine 5, 6, 7.

Safety of Sugammadex and Neostigmine

• Sugammadex has a better safety profile than neostigmine, with a lower incidence of adverse events such as bradycardia, postoperative nausea and vomiting, and postoperative residual paralysis 6.
• The risk of serious adverse events is similar between sugammadex and neostigmine 6.

Clinical Implications

• Sugammadex may be a useful addition to the clinician's armamentarium for acute neurologic assessment in the neurosurgical population, allowing for more informed decision-making by families and physicians alike 8.
• The use of sugammadex may impact clinical decision-making in certain patients, particularly in cases where timely and accurate assessment of patient neurological status is crucial 8.