What is the maintenance dose of rocuronium (neuromuscular blocking agent)?

Rocuronium Maintenance Dosing

For maintenance of neuromuscular blockade, rocuronium should be administered as intermittent boluses of 0.1-0.2 mg/kg when 25% recovery of T1 is reached, or as continuous infusion starting at 10-12 mcg/kg/min, adjusted to train-of-four (TOF) monitoring. 1

Intermittent Bolus Dosing

• Administer 0.1-0.2 mg/kg when T1 (first twitch) recovers to 25% of baseline 1
• In trauma patients and critically ill adults, maintenance boluses of 25 mg can be given when TOF shows 2 responses 2, 1
• The mean dose required to maintain 80% blockade in critically ill adults is approximately 0.34 mg/kg 1

Continuous Infusion Dosing

• Start infusion at 10-12 mcg/kg/min when T1 returns to 10% (one twitch present in train-of-four) 1, 3
• In critically ill patients, the median infusion rate to maintain one twitch is approximately 10 mcg/kg/min 1
• For profound neuromuscular blockade (0-2 posttetanic count), approximately 0.758 mg/kg/hr is required, with lower PTC targets requiring higher doses 4

Anesthetic-Specific Adjustments

• Under enflurane or isoflurane anesthesia, reduce infusion rate by up to 40% compared to opioid/nitrous oxide/oxygen anesthesia 3
• The median clinical duration under opioid/nitrous oxide/oxygen is 34 minutes, versus 38 minutes under enflurane and 42 minutes under isoflurane 3

Mandatory Monitoring Requirements

Quantitative neuromuscular monitoring at the adductor pollicis muscle is mandatory and must continue until TOF ratio ≥0.9 is obtained. 1, 5

• Failure to monitor can lead to overdosing or inadequate blockade, with residual neuromuscular blockade occurring in 28% of pediatric patients without proper monitoring 1
• After continuous infusion, TOF response typically returns approximately 60 minutes after stopping the infusion 1, 5

Special Population Adjustments

Patients on Pyridostigmine

• Do not modify initial dose, but reduce subsequent maintenance doses by 50-75% 5, 1
• TOF monitoring is absolutely mandatory in this population 5

Renal or Hepatic Impairment

• Do not modify initial dose, but expect potentially prolonged duration of action (approximately 1.5 times longer in hepatic disease) 1, 3
• Consider using benzylisoquinoline muscle relaxants (atracurium/cisatracurium) instead when possible 1

Pediatric Patients

• Maintenance boluses of 0.075-0.125 mg/kg upon return of T1 to 25% under halothane anesthesia 3
• Alternatively, continuous infusion at 12 mcg/kg/min upon return of T1 to 10% 3
• Under sevoflurane/isoflurane, administer 0.15 mg/kg at reappearance of T3, or infusion at 7-10 mcg/kg/min at reappearance of T2 3

Geriatric Patients

• No dose adjustment required for maintenance doses, though greater sensitivity in some older individuals cannot be ruled out 3

Critical Safety Considerations

• Rocuronium provides no sedation, analgesia, or amnesia—appropriate sedative and analgesic medications must be administered concurrently 1, 3
• Inhalational anesthetics potentiate rocuronium's effect, requiring dose reduction 1
• Anticonvulsants may increase maintenance requirements 2, 1

Reversal Considerations

• Sugammadex is the preferred reversal agent: 2 mg/kg at TOF count of 2-4, or 4 mg/kg at post-tetanic count of 1-2 1
• After continuous infusion for deep blockade, standard sugammadex 4 mg/kg takes approximately 2.85 minutes to achieve TOF ratio 0.9 4
• Neostigmine (0.04 mg/kg) with atropine (0.02 mg/kg) can be used when TOF count = 4, with efficacy in 10-20 minutes 1