Rocuronium very delayed response?

[bluewater]

I am currently a resident. I recently had a pt that was induced with fent and propofol. Easy to ventilate- 50 mg Roc given... talked golf/fishing for 3-4 minutes, sevo on the entire time.

I try to intubate and the cords are closed as if no relaxant had been given, 7.5 tube passed atraumatically, but with some difficulty. 10 mins post Roc dose- 4 twitches, 15-20 mins later- 0 twitches.

The IV was working fine.

Slightly troubling.

Any ideas-

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[militarymd]

roc does not have the same reliability as vec in terms of duration of action....I have seen it last MUCH longer than anticipated muliple times...over 10 years time.

as for delayed onset.....I haven't noticed.

 

[dhb]

Maybe a storage problem i think i degrades at room temp (0.25-0.5%/24h)...?

 

[ZA_Gasman]

I've seen the same thing. If you want it to act quickly then you really have to give the 1.1mg/kg dose, then you can (9.9 times out of 10) intubate after about 60-80secs. At this stage I find conditions are good, but not excellent for intubation. Any less than this though, and it seems to need at least 5 minutes before the patient is really properly relaxed.

I can't understand why it is presented in 50mg vials though, since on most of the cases where I'm using Roc, I open two vials in a 10ml syringe.

I think Rocuronium is over-rated, and I prefer Vec any day of the week, except for that rapid sequence 1-1.1mg/kg thing that you can do with Roc. Although, to be honest, I'd rather use Tracrium for modified rapid sequence. Although I trust my airway assessment skills, I wouldn't like to be sitting for 45-50minutes before I can reverse a patient that we can't intubate. Sugammadex will probably change my opinion here.

 

[ProwlerturnGas]

I've seen the same thing. If you want it to act quickly then you really have to give the 1.1mg/kg dose, then you can (9.9 times out of 10) intubate after about 60-80secs. At this stage I find conditions are good, but not excellent for intubation. Any less than this though, and it seems to need at least 5 minutes before the patient is really properly relaxed.

I can't understand why it is presented in 50mg vials though, since on most of the cases where I'm using Roc, I open two vials in a 10ml syringe.

I think Rocuronium is over-rated, and I prefer Vec any day of the week, except for that rapid sequence 1-1.1mg/kg thing that you can do with Roc. Although, to be honest, I'd rather use Tracrium for modified rapid sequence. Although I trust my airway assessment skills, I wouldn't like to be sitting for 45-50minutes before I can reverse a patient that we can't intubate. Sugammadex will probably change my opinion here.

Hello to my South African anesthesiologist brother.
We have two attendings from SA at my program. Both leaders in Regional. Is regional pretty popular in South Africa?
I too cannot wait to play with Sugammadex. In my experience, CA-2, Roc is weird stuff. I have seen a few patients now with delayed TOF out of proportion to dose and have even had to place a patient on a vent in the PACU while waiting for the stuff to wear off. I have never used Tracrium for MRSI, we only have Nimbex, which I wouldnt use for MRSI.

PTG

 

[Mman]

can't understand why it is presented in 50mg vials though, since on most of the cases where I'm using Roc, I open two vials in a 10ml syringe.

We get Roc in 10 ml vials of 10 mg/ml

 

[Noyac]

I rarely use more than 50 mg of Roc for any case 3 hrs or less. Narcs and gas keeps them pretty relaxed. Sure there are some cases that need a lot of relaxation not that often. So you have to wait a little longer. It shouldn't delay the start of the case. They can still prep while you are waiting to intubate.

 

[ZA_Gasman]

We have two attendings from SA at my program. Both leaders in Regional. Is regional pretty popular in South Africa?

PTG

Hi PTG.
Don't think regional is any more popular here than anywhere else. We certainly aren't as fanatical about regionals as our European cousins,but there are definitely quite a few guys here who do them a lot.

Z_G

 

[nimbus]

I rarely use more than 50 mg of Roc for any case 3 hrs or less. Narcs and gas keeps them pretty relaxed. Sure there are some cases that need a lot of relaxation not that often. So you have to wait a little longer. It shouldn't delay the start of the case. They can still prep while you are waiting to intubate.

Totally agree. I routinely intubate with rocuronium 30 mg in normal sized (70-80kg) patients. Works fine. I still use sux for RSI.