Nondepolarizing NMB
Rocuronium
Zemuron Neuromuscular blocker — fluorescent red 10 mg/mL
The workhorse paralytic; high dose gives RSI-speed onset and sugammadex reverses it.
Typical adult doses
| Indication | Dose | Onset | Duration |
|---|---|---|---|
| Intubation | 0.6 mg/kg IV | ≈1.5–2 min | ≈30–40 min (clinical) |
| Rapid sequence | 1–1.2 mg/kg IV | ≈60 s | ≈60+ min |
| Maintenance | 0.1–0.2 mg/kg IV | — | — |
Mechanism
Competitive antagonist at nicotinic ACh receptors (aminosteroid).
Key effects
- Skeletal-muscle paralysis — no sedation or analgesia
Watch out for
- Anaphylaxis (NMBAs are a leading cause of perioperative anaphylaxis)
- Prolonged in liver disease and the elderly
- Burning on injection in awake patients
- Dosing weight in obesity: discuss (ideal vs. actual)
- Label “clinical duration” = T1 back to 25% — not full recovery
Reversal
Sugammadex by depth, or neostigmine + glycopyrrolate only at minimal depth (ASA 2023). Confirm quantitative TOF ratio ≥ 0.9.
Pimp questions
Pimp question 1
What reverses rocuronium from a deep block?
Answer
Sugammadex (encapsulation). Neostigmine cannot — it has a ceiling effect.
Pimp question 2
A paralyzed, motionless patient — does that prove adequate anesthesia?
Answer
No. Paralysis and hypnosis are separate; NMBs have no sedative or analgesic effect.