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.
Toxicity and Overdose:
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.
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.
IV Push: Administer undiluted.
Rate: Titrate according to patient response.
Continuous Infusion: Dilution: 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.
hydrocortisone sodium phosphate
amphotericin B lipid complex
hydrocortisone sodium succinate
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.
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.
rocuronium is a sample topic from the Davis's Drug Guide.
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