Rocuronium and Renal Failure

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uclalee

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So it seems like people in my program generally avoid Rocuronium in patient with renal failure and prefer to use Cisatracurium. But Roc isn't metabolized and is excreted through the bile. Is there any reason to avoid Roc in a patient with renal failure?

Thanks.
 
uclalee said:
So it seems like people in my program generally avoid Rocuronium in patient with renal failure and prefer to use Cisatracurium. But Roc isn't metabolized and is excreted through the bile. Is there any reason to avoid Roc in a patient with renal failure?

Thanks.
Click to expand...


That's academia for you.
 
Highly dependent on the situation (surgical procedure, "adequately fasted" vs. full stomach, case duration, comorbities, etc.) If you need to rapidly secure an airway would you rather use succinylcholine? Academic institutions are classic for debating about whether or not succinylcholine will raise the serum potassium value significantly to cause problems.
 
great timing, since my institution has completely run out of cis for at least a month (that's nothing, been out of vec for several months) , and now we're being forced to use roc for pt's with renal failure. Only done it a few times so far, but have not noticed any differences at all; redosing seems similar to people with normal renal function...
 
I looked into this a few months ago (specifically re using rocuronium in kidney transplant pts). IIRC, data indicates only a slight increase in duration of action. Having said that, most attendings I've worked with still seem to prefer cis-atracurium in this pt population.
 
the only NMBD you have to worry about in renal failure are the long acting ones....
Roc is a fantasic drug, i love it... now that its generic there is rarely a reason to give anything else
 
amyl said:
the only NMBD you have to worry about in renal failure are the long acting ones....
Roc is a fantasic drug, i love it... now that its generic there is rarely a reason to give anything else
Click to expand...


I don't understand why it is so much better than vec (other than obviating the need to reconstitute)
 
Bertelman said:
I don't understand why it is so much better than vec (other than obviating the need to reconstitute)
Click to expand...

I agree. With the vec shortage, we gained a lot of experience with roc. Other than the onset of action, there's little to like. At least with vec I can predict when it's going to wear off and residual paralysis was something I only read about.
 
Yeah, gotta say roc sucks compared to vec. So much less predictable.
 
Hmmm....we never use vec at ours. Only roc and cis (cis in renal) - what's oh so good about vec? I have seen it laying around in the powder form...just never cared to mix it.
 
So what I'm hearing is that there is really no definitive benefit v. either. Sounds a lot like personal preference. We use vec primarily because it is stocked in our drawers. Roc is still brand-name at our place, and stored in the fridge far away. I've used it a couple times for RSI, but that's about it. I will say that dosing vec is much more intuitive. Divide kg by 10.

As for the speed of onset, You can always give a pre- dose of vec, or increase the dose, or both. That's basically how you're getting the faster onset of roc anyways, right? I generally give a cc before induction, then standard dose. With enough narcotic, I'll intubate within 2 min, and I can't recall the last time I had much beyond a little cough when I hit the trachea.
 
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Fair enough. I will say that I get nice quality time with my attending waiting for that vec to kick in.


I'd miss that if I switched to roc. 😉
 
DreamMachine said:
Both predictable in duration.
Both intermediate acting.
Both MAY be slightly prolonged in renal failure.
Both don't release histamine.

Roc has a faster onset.
Roc doesn't need to be mixed up.
Click to expand...


One thing I've noticed about Roc - if it's been out of the refrigerator for a long time, it's less potent. Slower onset than expected, and requires more than expected. But I still like using it.
 
Eur J Anaesthesiol. 2005 Jan;22(1):4-10.
Pharmacokinetics and pharmacodynamics of rocuronium in patients with and without renal failure.

Robertson EN, Driessen JJ, Booij LH.
University Medical Center, Department of Anesthesiology, Nijmegen, The Netherlands. [email protected]
BACKGROUND AND OBJECTIVE: This study clarifies the relationship between the neuromuscular blocking effects of rocuronium 0.6 mg kg(-1) and its pharmacokinetics in patients with renal failure. METHODS: Seventeen healthy patients and 17 patients with renal failure were studied under propofol anaesthesia in this prospective open label study. Rocuronium 0.6 mg kg(-1) was given after induction of anaesthesia. The train-of-four mechano-myographic response of the thumb to supramaximal stimulation of the ulnar nerve at 2 Hz every 12 s was measured. Venous blood samples (4 mL) were obtained at 0, 2, 4, 7, 10, 15, 20, 30, 60, 120, 180, 240 and 360 min after relaxant administration. Samples were centrifuged, separated and stored at -20 degrees C until plasma levels of rocuronium and its metabolites were measured. Two- and three-exponential equations were used to describe the pharmacokinetic data in each group and these were compared to each other using the Wilcoxon signed rank sum test as was the pharmacodynamic data. P < 0.05 was significant. RESULTS: Onset of block was similar in both groups. Clinical duration and the time to recovery of the train-of-four to 70% were prolonged in the renal failure group compared to control; 49 vs. 32 min (P < 0.004, 95% confidential, interval 17, difference 5-28) and 88 vs. 55 min (P < 0.001, 95% confidential interval 33, difference 17-50), respectively. Clearance of rocuronium was reduced by 39% in the renal failure patients compared to control, with an 84% increase in the mean residence time. The volume of distribution was unaffected by renal failure. CONCLUSIONS: The duration of action of a bolus dose of 0.6 mg kg(-1) rocuronium is increased significantly in patients with end-stage renal failure compared to healthy controls. This increase may be due to a decreased clearance of rocuronium, the disease process causing the renal failure and/or the medication which patients with renal failure need in their treatment.

PMID: 15816565 [PubMed - indexed for MEDLINE]

javascript:AL_get(this, 'ptyp', 'Research Support, Non-U.S. Gov\'t');

 
Renal Failure: Due to the limited role of the kidney in the excretion of ZEMURON™ (rocuronium bromide) Injection, usual dosing guidelines should be adequate. ZEMURON™ 0.6 mg/kg has been evaluated in three single center trials (n=30, ages 19-61 years) in patients undergoing renal transplant surgery, or shunt procedures in preparation for dialysis. After ZEMURON™ 0.6 mg/kg, the time to maximum block was about 1-2 minutes and was not different from patients without renal dysfunction. The mean ± SD clinical duration of 54 ± 22 minutes was not considered prolonged compared to 46 ± 12 minutes in normal patients; however, there was substantial variation (range, 22-90 minutes). The spontaneous recovery rate from 25 to 75% of control in renal dysfunction patients of 27 ± 11 minutes was similar to 28 ± 20 minutes in normal patients (see Pharmacokinetics subsection of CLINICAL PHARMACOLOGY).



In general, patients undergoing cadaver kidney transplant have a small reduction in clearance which is offset pharmacokinetically by a corresponding increase in volume, such that the net effect is an unchanged plasma half-life. Patients with demonstrated liver cirrhosis have a marked increase in their volume of distribution resulting in a plasma half-life approximately twice that of patients with normal hepatic function. Table 4 shows the pharmacokinetic parameters in subjects with either impaired renal or hepatic function.
Table 4. Pharmacokinetic Parameters in Adults with Normal Renal and Hepatic Function (n=10, ages 23-65),

Renal Transplant Patients (n=10, ages 21-45) and Hepatic Dysfunction Patients (n=9, ages 31-67)During Isoflurane Anesthesia (Mean ± SD)
zemuron4.gif
 
ProRealDoc said:
Renal Failure: Due to the limited role of the kidney in the excretion of ZEMURON&#8482; (rocuronium bromide) Injection, usual dosing guidelines should be adequate. ZEMURON&#8482; 0.6 mg/kg has been evaluated in three single center trials (n=30, ages 19-61 years) in patients undergoing renal transplant surgery, or shunt procedures in preparation for dialysis. After ZEMURON&#8482; 0.6 mg/kg, the time to maximum block was about 1-2 minutes and was not different from patients without renal dysfunction. The mean ± SD clinical duration of 54 ± 22 minutes was not considered prolonged compared to 46 ± 12 minutes in normal patients; however, there was substantial variation (range, 22-90 minutes). The spontaneous recovery rate from 25 to 75% of control in renal dysfunction patients of 27 ± 11 minutes was similar to 28 ± 20 minutes in normal patients (see Pharmacokinetics subsection of CLINICAL PHARMACOLOGY).



In general, patients undergoing cadaver kidney transplant have a small reduction in clearance which is offset pharmacokinetically by a corresponding increase in volume, such that the net effect is an unchanged plasma half-life. Patients with demonstrated liver cirrhosis have a marked increase in their volume of distribution resulting in a plasma half-life approximately twice that of patients with normal hepatic function. Table 4 shows the pharmacokinetic parameters in subjects with either impaired renal or hepatic function.
Table 4. Pharmacokinetic Parameters in Adults with Normal Renal and Hepatic Function (n=10, ages 23-65),

Renal Transplant Patients (n=10, ages 21-45) and Hepatic Dysfunction Patients (n=9, ages 31-67)During Isoflurane Anesthesia (Mean ± SD)
zemuron4.gif
Click to expand...

Proreal glad to see you posting again.
A wise man once told me get it however you can by any means necessary!!!
Keep up the good fight.
 
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