DOSING: 2-2.

5 mg/kg
PROPOFOL

CLINICAL PHARMACOLOGY: 9 a 51 sec (rango 30 sec)

INDICATIONS: Induction of anesthesia in patients ≥3 years of age; maintenance of anesthesia in patients >2
months of age; in adults, for monitored anesthesia care sedation during procedures; in adults, for sedation in
intubated, mechanically-ventilated ICU patients.

ADVERSE REACTIONS: Induction of anesthesia in patients ≥3 years of age; maintenance of anesthesia in patients
>2 months of age; in adults, for monitored anesthesia care sedation during procedures; in adults, for sedation in
intubated, mechanically-ventilated ICU patients.

ETOMIDATO DOSING:IV: Initial: 0.1 to 0.2 mg/kg, followed by 0.05 mg/kg every 3 to 5 minutes as needed

CLINICAL PHARMACOLOGY: Onset of action: 30 to 60 seconds, Peak effect: 1 minute, Duration: Dose
dependent: 2 to 3 minutes (0.15 mg/kg dose); 3 to 5 minutes (0.3 mg/kg dose); rapid recovery is due
to rapid redistribution
INDICATIONS:Induction of general anesthesia; as a supplement to subpotent anesthetic agents
during maintenance of anesthesia for short operative procedures (eg, dilation and curettage, cervical
conization)
ADVERSE REACTIONS:>10%:
Central nervous system: Myoclonus (33%)
Endocrine & metabolic: Adrenal suppression
Gastrointestinal: Nausea, vomiting (on emergence from anesthesia)
Local: Pain at injection site (30% to 80%)
Neuromuscular & skeletal: Musculoskeletal disease (transient skeletal movements)
Ophthalmic: Nystagmus
1% to 10%: Gastrointestinal: Hiccups
<1%, postmarketing, and/or case reports: Apnea, bradycardia, cardiac arrhythmia, decreased cortisol
(decreased cortisol synthesis), hypertension, hyperventilation, hypotension, hypoventilation,
laryngospasm, muscle spasm (masseter; Bozeman 2002), tachycardia
MIDAZOLAM DOSING nduction: Adults <55 years:
Unpremedicated patients: Initial: 0.3 to 0.35 mg/kg over 20 to 30 seconds; after 2 minutes, may repeat if necessary
at ~25% of initial dose every 2 minutes, up to a total dose of 0.6 mg/kg in resistant cases.
Premedicated patients: Usual dosage range: 0.05 to 0.2 mg/kg (Barash 2009; Miller 2010). Use of 0.2 mg/kg
administered over 5 to 10 seconds has been shown to safely produce anesthesia within 30 seconds (Samuelson
1981) and is recommended for ASA physical status P1 and P2 patients. When used with other anesthetic drugs (ie,
co-induction), the dose is <0.1 mg/kg (Miller 2010).
ASA physical status >P3 or debilitation: Reduce dose by at least 20% (Miller 2010).
Maintenance: 0.05 mg/kg as needed (Miller 2010), or continuous infusion 0.015 to 0.06 mg/kg/hour (0.25 to 1
mcg/kg/minute) (Barash 2009; Miller 2010)

CLINICAL PHARMACOLOGY:Onset of action: IM: Sedation: Children: Within 5 minutes; Adults: ~15 minutes; IV: 3 to
5 minutes; Oral: 10 to 20 minutes; Intranasal: Children: 5.55 ± 2.22 minutes (Lee-Kim 2004); Adults: Within 5
minutes
Peak effect: IM: Children: 15 to 30 minutes; Adults: 30 to 60 minutes; IV: 3 to 5 minutes; Intranasal: Children: 10
minutes (al-Rakaf 2001)
Duration: IM: Up to 6 hours; Mean: 2 hours; Intranasal: Children: 23.1 minutes (Chiaretti 2011); IV: Single dose: <2
hour

INDICATIONS Anesthesia: IV: Induction of general anesthesia before administration of other anesthetic agents;
maintenance of anesthesia as a component of balanced anesthesia.
Sedation/anxiolysis/amnesia (preoperative/procedural):
IM: Preoperative sedation, anxiolysis, and amnesia.
IV: Sedation, anxiolysis, and amnesia prior to or during diagnostic, therapeutic, or endoscopic procedures, or prior
to surgery.
Oral: Sedation, anxiolysis, and amnesia in children prior to diagnostic, therapeutic or endoscopic procedures or
before induction of anesthesia.
Sedation for mechanically-ventilated patients: IV: Sedation of intubated and mechanically-ventilated patients as a
component of anesthesia or during treatment in a critical care setting by continuous IV infusion.

ADVERSE REACTIONS: >10%: Respiratory: Bradypnea, decreased tidal volume

1% to 10%:
Cardiovascular: Hypotension (children: 3%)
Central nervous system: Drowsiness (1%), headache (1%), seizure-like activity (children: 1%), drug dependence
(physical and psychological dependence with prolonged use), myoclonus (preterm infants), severe sedation
Gastrointestinal: Hiccups (adults: 4%; children: 1%), nausea (3%), vomiting (3%)
Local: Injection site reaction (IM: ≤4%, IV: ≤5%; severity less than diazepam), pain at injection site (IM: ≤4%, IV:
≤5%; severity less than diazepam)
Ophthalmic: Nystagmus (children: 1%)
Respiratory: Apnea (children: 3%), cough (1%)
Miscellaneous: Paradoxical reaction (children: 2%)
<1%, postmarketing, and/or case reports: Acidic taste, agitation, amnesia, bigeminy, bradycardia, bronchospasm,
confusion, delirium (emergence), dyspnea, euphoria, hallucination, hyperventilation, laryngospasm, sialorrhea, skin
rash, tachycardia, ventricular premature contractions, wheezing
FENTANILO
CLINICAL PHARMACOLOGY: Onset of action:
Children 3 to 12 years: Intranasal: 5 to 10 minutes (Borland 2002)
Adults: Analgesic: IM: 7 to 8 minutes; IV: Almost immediate (maximal analgesic and respiratory depressant effects may
not be seen for several minutes); Transdermal patch (initial placement): 6 hours; Transmucosal: 5 to 15 minutes
Duration: IM: 1 to 2 hours; IV: 0.5 to 1 hour; Transdermal (removal of patch/no replacement): Related to blood level; some
effects may last 72 to 96 hours due to extended half-life and absorption from the skin, fentanyl concentrations decrease
by ~50% in 20 to 27 hours; Transmucosal: Related to blood level; respiratory depressant effect may last longer than
analgesic effect
Absorption:
Transdermal, patch: Initial application: Drug is released at a nearly constant rate from the transdermal matrix system into
the skin, where it accumulates; this results in a depot of fentanyl in the outer layer of skin. Fentanyl is absorbed into
systemic circulation from the depot. This results in a gradual increase in serum concentration over the first 12 to 24 hours,
followed by fairly constant concentrations for the remainder of the dosing interval. Absorption is decreased in cachectic
patients (compared to normal size patients). Exposure to external heat increases drug absorption from patch.
Transdermal, device: At the activation of each dose, an electrical current is activated for 10 minutes, which moves a dose
of fentanyl from the drug-containing reservoir through the skin and into the systemic circulation. Fentanyl concentrations
increase slowly with device activation and continue to increase for ~5 minutes after the completion of each 10 minute
dose. Absorption of fentanyl from the device increases as a function of time and is independent of frequency of dosing.
Transmucosal, buccal tablet and buccal film: Rapid, ~50% from the buccal mucosa; remaining 50% swallowed with saliva
and slowly absorbed from GI tract.
Transmucosal, lozenge: Rapid, ~25% from the buccal mucosa; 75% swallowed with saliva and slowly absorbed from GI
tract
Distribution: Highly lipophilic, redistributes into muscle and fat; Note: IV fentanyl exhibits a 3-compartment distribution
model. Changes in blood pH may alter ionization of fentanyl and affect its distribution between plasma and CNS
Vdss: Children: 0.05 to 14 years of age (after long-term continuous infusion): ~15 L/kg (range: 5 to 30 L/kg)
Vdss: Adults: 4 to 6 L/kg
Protein binding: 79% to 87%, primarily to alpha-1 acid glycoprotein; also binds to albumin and erythrocytes; Note: Free
fraction increases with acidosis
Metabolism: Hepatic, primarily via CYP3A4 by N-dealkylation (to norfentanyl) and hydroxylation to other inactive
metabolites
Bioavailability: Note: Comparative studies have found the buccal film to have a 40% greater systemic exposure (ie, AUC)
than the transmucosal lozenge, and the buccal tablet to have a 30% to 50% greater exposure than the transmucosal
lozenge.
Buccal film: 71% (mucositis did not have a clinically significant effect on Cmax and AUC; however, bioavailability is
expected to decrease if film is inappropriately chewed and swallowed)
Buccal tablet: 65%
Lozenge: ~50%
Sublingual spray: 76%
Sublingual tablet: 54%
Half-life elimination:
IV:
Pediatric patients 5 months to 4.5 years: 2.4 hours
Pediatric patients 6 months to 14 years (after long-term continuous infusion): ~21 hours (range: 11-36 hours)
Adults: 2 to 4 hours; when administered as a continuous infusion, the half-life prolongs with infusion duration due to the
large volume of distribution (Sessler 2008)
Transdermal device: Terminal: ~16 hours
Transdermal patch: 20 to 27 hours (apparent half-life is influenced by continued fentanyl absorption from skin)
Transmucosal products: 3 to 14 hours (dose dependent)
Intranasal: 15 to 25 hours (based on a multiple-dose pharmacokinetic study when doses are administered in the same
nostril and separated by a 1-, 2-, or 4-hour time lapse)
Buccal film: ~14 hours
Buccal tablet: 100-200 mcg: 3 to 4 hours; 400 to 800 mcg: 11 to 12 hours
Time to peak:
Buccal film: 0.75 to 4 hours (median: 1 hour)
Buccal tablet: 20 to 240 minutes (median: 47 minutes)
Lozenge: 20 to 480 minutes (median: 20 to 40 minutes)
Intranasal: Median: 15 to 21 minutes
Sublingual spray: 10 to 120 minutes (median: 90 minutes)
Sublingual tablet: 15 to 240 minutes (median: 30 to 60 minutes)
Transdermal patch: 20 to 72 hours; steady state serum concentrations are reached after two sequential 72-hour
applications
Excretion: Urine 75% (primarily as metabolites, <7% to 10% as unchanged drug); feces ~9%
Clearance: Newborn infants: Clearance may be significantly correlated to gestational age and birth weight (Saarenmaa
2000)

INDICATIONS:
Injection:Surgery: Adjunct to general or regional anesthesia; preoperative medication; analgesic during anesthesia and in
the immediate postoperative period.
Transdermal device (eg, Ionsys): Postoperative pain, acute: Short-term management of acute postoperative pain severe
enough to require an opioid analgesic in the hospital and for which alternative treatments are inadequate.
Limitations of use: Reserve for use in patients for whom alternative treatment options (eg, nonopioid analgesics) are
ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain. Only for use in
patients who are alert enough and have adequate cognitive ability to understand the directions for use. Not for home use.
Transdermal device is for use only in patients in the hospital. Discontinue treatment with the device before patients leave
the hospital. The device is for use after patients have been titrated to an acceptable level of analgesia using alternate
opioid analgesics.
Transdermal patch (eg, Duragesic):Chronic pain: Management of pain in opioid-tolerant patients, severe enough to
require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.
Limitations of use: Reserve for use in patients for whom alternative treatment options (eg, nonopioid analgesics,
immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient
management of pain. Not indicated as an as-needed analgesic.
Transmucosal lozenge (eg, Actiq), buccal tablet (Fentora), buccal film (Onsolis), intranasal (Lazanda), sublingual tablet
(Abstral), sublingual spray (Subsys):Cancer pain: Management of breakthrough cancer pain in opioid-tolerant patients ≥18
years (Abstral, Fentora, Lazanda, Onsolis, Subsys) and ≥16 years (Actiq) who are already receiving and who are tolerant
to around-the-clock opioid therapy for their underlying persistent cancer pain.
Limitations of use: Not for use in opioid non-tolerant patients. Not for use in the management of acute or postoperative
pain, including headache/migraine, dental pain, or in the emergency department. As a part of the TIRF REMS Access
program, these products may be dispensed only to outpatients enrolled in the program. For inpatient administration (eg,
hospitals, hospices, and long-term care facilities that prescribe for inpatient use), patient and prescriber enrollment is not
required.
Note: "Opioid-tolerant" patients are defined as patients who are taking at least:
Oral morphine 60 mg/day, or
Transdermal fentanyl 25 mcg/hour, or
Oral oxycodone 30 mg/day, or
Oral hydromorphone 8 mg/day, or
Oral oxymorphone 25 mg/day, or
Oral hydrocodone 60 mg/day, or
Equianalgesic dose of another opioid for at least 1 week

ADVERSE REACTIONS:
>10%:
Central nervous system: Confusion, dizziness, drowsiness, fatigue, headache, sedation
Endocrine & metabolic: Dehydration
Gastrointestinal: Constipation, nausea, vomiting
Local: Application site erythema (transdermal device)
Neuromuscular & skeletal: Weakness
Respiratory: Dyspnea
KETAMINA
DOSING:
May administer atropine, scopolamine, or another drying agent prior to induction and at appropriate intervals to decrease
hypersalivation. Note: Titrate dose for desired effect.
Anesthesia:
Induction of anesthesia:
Manufacturer's labeling:
IM: 6.5 to 13 mg/kg
IV: 1 to 4.5 mg/kg
Alternate recommendations (off-label dosing): Note: lower doses may be used if adjuvant drugs (eg, midazolam) are
administered (Miller 2010)
IM: 4 to 10 mg/kg (Green 1990; Miller 2010; White 1982)
IV: 0.5 to 2 mg/kg (Miller 2010; White 1982)
Maintenance of anesthesia: May administer supplemental doses of one-half to the full induction dose or a continuous
infusion of 0.1 to 0.5 mg/minute (per manufacturer). Note: To maintain an adequate concentration of ketamine for
maintenance of anesthesia, 1 to 2 mg/minute has been recommended (White 1982); doses in the range of 15 to 90
mcg/kg/minute (~1 to 6 mg/minute in a 70-kg patient) have also been suggested (Miller 2010). Concurrent use of nitrous
oxide reduces ketamine requirements. Recent laboratory/clinical studies support the use of low-dose ketamine to improve
postoperative analgesia/outcome (Adam 2005; Menigaux 2000)

CLINICAL PHARMACOLOGY:
Mechanism of Action
Produces a cataleptic-like state in which the patient is dissociated from the surrounding environment by direct action on
the cortex and limbic system. Ketamine is a noncompetitive NMDA receptor antagonist that blocks glutamate. Low
(subanesthetic) doses produce analgesia, and modulate central sensitization, hyperalgesia and opioid tolerance. Reduces
polysynaptic spinal reflexes.
Pharmacodynamics/Kinetics
Onset of action:
IV: Anesthetic effect: Within 30 seconds
IM: Anesthetic effect: 3 to 4 minutes; Analgesia: Within 10 to 15 minutes
Intranasal: Analgesic effect: Within 10 minutes (Carr 2004); Sedation: Children 2 to 6 years: 5 to 8 minutes (Bahetwar
2011)
Oral: Analgesia: Within 30 minutes; Sedation: Children 2 to 8 years (Turhanoglu 2003):
4 mg/kg/dose: 12.9 ± 1.9 minutes
6 mg/kg/dose: 10.4 ± 2.9 minutes
8 mg/kg/dose: 9.5 ± 1.9 minutes
Duration:
IV: Anesthetic effect: 5 to 10 minutes; Recovery: 1 to 2 hours
IM: Anesthetic effect: 12 to 25 minutes; Analgesia: 15 to 30 minutes; Recovery: 3 to 4 hours
Intranasal: Analgesic effect: Up to 60 minutes (Carr 2004); Recovery: Children 2 to 6 years: 34 to 46 minutes (Bahetwar
2011)
Distribution: Vdss: 2.4 L/kg (Wagner 1997)
Protein binding: 27% (Brunton 2006)
Metabolism: Hepatic via N-dealkylation (metabolite I [norketamine]), hydroxylation of the cyclohexone ring (metabolites III
and IV), conjugation with glucuronic acid and dehydration of the hydroxylated metabolites to form the cyclohexene
derivative (metabolite II); metabolite I (norketamine) is 33% as potent as parent compound. When administered orally,
norketamine concentrations are higher compared to other routes of administration due to extensive first-pass metabolism
in the liver (Blonk 2010; Soto 2012).
Bioavailability:
IM: 93%
Oral: 20% to 30% (Miller 2010)
Intranasal: Children, Adolescents, and Adults: Mean range: 35% to 50% (Malinovsky 1996; Miller 2010; Nielsen 2014)
Rectal: Children 2 to 9 years: 25% (Malinovsky 1996)
Half-life elimination: Alpha: 10 to 15 minutes; Beta: 2.5 hours
Time to peak, plasma:
IM: 5 to 30 minutes (Clements 1982)
Intranasal: 10 to 14 minutes (Huge 2010); Children 2 to 9 years: ~20 minutes (Malinovsky 1996)
Oral: ~30 minutes (Soto 2012)
Rectal: Children 2 to 9 years: ~45 minutes (Malinovsky 1996)
Excretion: Urine (91%); feces (3%) (Ghoneim 1977)

INDICATIONS: Anesthesia: Induction and maintenance of general anesthesia

ADVERSE REACTIONS:

>10%: Central nervous system: Prolonged emergence from anesthesia (12%; includes confusion, delirium, dreamlike
state, excitement, hallucinations, irrational behavior, vivid imagery)
Frequency not defined:
Cardiovascular: Bradycardia, cardiac arrhythmia, hypotension, increased blood pressure, increased pulse
Central nervous system: Drug dependence, hypertonia (tonic-clonic movements sometimes resembling seizures),
increased cerebrospinal fluid pressure
Dermatologic: Erythema (transient), morbilliform rash (transient), rash at injection site
Endocrine & metabolic: Central diabetes insipidus (Hatab 2014)
Gastrointestinal: Anorexia, nausea, sialorrhea (Hatab 2014), vomiting
Genitourinary (reactions can be severe in patients with a history of chronic ketamine use/abuse): Bladder dysfunction
(reduced capacity), cystitis (including cystitis noninfective, cystitis interstitial, cystitis ulcerative, cystitis erosive, cystitis
hemorrhagic), dysuria, hematuria, urinary frequency, urinary incontinence, urinary urgency
Hypersensitivity: Anaphylaxis
Local: Pain at injection site
Neuromuscular & skeletal: Laryngospasm
Ophthalmic: Diplopia, increased intraocular pressure, nystagmus
Renal: Hydronephrosis
Respiratory: Airway obstruction, apnea, respiratory depression

SUCCINILCOLINA
DOSING: Neuromuscular blockade: Dose to effect; doses will vary due to interpatient variability. Use carefully and/or
consider dose reduction in patients with reduced plasma cholinesterase activity due to genetic abnormalities of plasma
cholinesterase or when associated with other conditions (eg, electrolyte abnormalities, neuromuscular disease);
prolonged neuromuscular blockade may occur.
IM: Up to 3 to 4 mg/kg, maximum total dose: 150 mg
IV:
Intubation: 0.6 mg/kg (range: 0.3 to 1.1 mg/kg)
Intubation (rapid sequence) (off-label dosing): 1 to 1.5 mg/kg (Sluga 2005; Weiss 1997)
Long surgical procedures (intermittent administration): Initial: 0.3 to 1.1 mg/kg; administer 0.04 to 0.07 mg/kg at
appropriate intervals as needed.
Note: Pretreatment with atropine may reduce occurrence of bradycardia. Initial dose of succinylcholine must be increased
when nondepolarizing agent pretreatment is used because of the antagonism between succinylcholine and
nondepolarizing neuromuscular-blocking agents (Miller 2010). When the cumulative dose of succinylcholine exceeds 2 to
4 mg/kg under general anesthesia or succinylcholine is administered by continuous infusion, transition from a phase I to a
phase II block may occur. If phase II block is suspected, diagnosis should be confirmed by peripheral nerve stimulation
prior to administration of an anticholinesterase drug (Hilgenberg 1981).

CLINICAL PHARMACOLOGY:

Mechanism of Action
Acts similar to acetylcholine, produces depolarization of the motor endplate at the myoneural junction which causes
sustained flaccid skeletal muscle paralysis produced by state of accommodation that develops in adjacent excitable
muscle membranes
Pharmacodynamics/Kinetics
Onset of action: Dependent on route, age, and dose; data suggest faster onset with higher doses (Coté 2013):
IM: Infants and Children: 3 to 4 minutes (Lui 1981); Adults: 2 to 3 minutes
IV:
Neonates and Infants: ~30 seconds (range: 19 to 40 seconds [dose: 2 to 4 mg/kg]) (Meakin 1990)
Children and Adolescents: 35 to 55 seconds (Coté 2013); Dose-specific: 40 seconds (dose: 1.5 to 2 mg/kg); 50 seconds
(dose: 1 mg/kg) (Coté 2013)
Adults: Flaccid paralysis: <60 seconds
Duration: Dependent on route, age, and dose
IM: 10 to 30 minutes; Observed to be shorter in infants than children
IV: ~4 to 6 minutes; Faster recovery rate in infants and children compared to adults (Fisher 1975)
Distribution: Vd higher in neonates and infants due to larger ECF volume; higher IV doses necessary
Metabolism: Rapidly hydrolyzed by plasma pseudocholinesterase to inactive metabolites
Excretion: Urine (~10% excreted unchanged)

INDICATIONS: Neuromuscular blockade: As an adjunct to general anesthesia, to facilitate tracheal intubation, and to
provide skeletal muscle relaxation during surgery or mechanical ventilation.
Note: Does not relieve pain or produce sedation

ADVERSE REACTIONS:
Frequency not defined.
Cardiovascular: Bradycardia (higher with second dose; more frequent in children), cardiac arrhythmia, hypertension,
hypotension, malignant hyperthermia, tachycardia
Dermatologic: Skin rash
Endocrine & metabolic: Hyperkalemia
Gastrointestinal: Sialorrhea
Hypersensitivity: Anaphylaxis
Neuromuscular & skeletal: Fasciculations, jaw tightness, myalgia (postoperative), rhabdomyolysis (with possible
myoglobinuric acute renal failure)
Ophthalmic: Increased intraocular pressure
Respiratory: Apnea, respiratory depression (prolonged)
<1%, postmarketing, and/or case reports: Abnormal bone growth (myositis ossificans; prolonged use), myopathy (acute
quadriplegic myopathy syndrome; prolonged use)

RUCURONIO
DOSING: Dosing: Adult
Dose to effect; doses will vary due to interpatient variability. Dosing also dependent on anesthetic technique and age of
patient.
Rapid sequence intubation: IV: 0.6 to 1.2 mg/kg
Obesity: In adult patients with morbid obesity (BMI >40 kg/m2), the use of 1.2 mg/kg using ideal body weight (IBW)
provided a short onset of action and excellent or good intubating conditions at 60 seconds in one study (Gaszynski 2011).
Tracheal intubation: IV:
Initial: 0.45 to 0.6 mg/kg; administration of 0.3 mg/kg may also provide optimal conditions for tracheal intubation (Barclay
1997)
Obesity: May use ideal body weight (IBW) for morbidly obese (BMI >40 kg/m2) adult patients (Leykin 2004; Meyhoff
2009); onset time may be slightly delayed using IBW. The manufacturer recommends dosing based on actual body weight
in all obese patients.
Maintenance for continued surgical relaxation: 0.1 to 0.2 mg/kg; repeat as needed or a continuous infusion of 10 to 12
mcg/kg/minute (0.6 to 0.72 mg/kg/hour) only after recovery of neuromuscular function is evident; infusion rates have
ranged from 4 to 16 mcg/kg/minute (0.24 to 0.96 mg/kg/hour)
Note: Inhaled anesthetic agents prolong the duration of action of rocuronium. Use lower end of the dosing range; redosing
interval guided by monitoring with a peripheral nerve stimulator.
Preinduction defasciculation (off-label use): IV: 0.03 to 0.06 mg/kg given 1.5 to 3 minutes before administration of
succinylcholine (Harvey 1998; Martin 1998)
ICU paralysis (eg, facilitate mechanical ventilation) in adequately sedated patients (off-label use): Initial bolus dose: 0.6 to
1 mg/kg, then a continuous IV infusion of 8 to 12 mcg/kg/minute (0.48 to 0.72 mg/kg/hour); monitor depth of blockade
every 2 to 3 hours initially until stable dose, then every 8 to 12 hours; adjust rate of administration by 10% increments
according to peripheral nerve stimulation response or desired clinical response (Greenberg 2013; Murray 2002; Rudis
1996; Sparr 1997; Warr 2011).
Note: When possible, minimize depth and duration of paralysis. Stopping the infusion for some time until forced to restart
based on patient condition is recommended to reduce post-paralytic complications (eg, acute quadriplegic myopathy
syndrome [AQMS]) (Murray 2002).
Intermittent dosing has also been described with an initial loading dose of 50 mg followed by 25 mg given when peripheral
nerve stimulation returns (Sparr 1997).

CLINICAL PHARMACOLOGY:

Mechanism of Action
Blocks acetylcholine from binding to receptors on motor endplate inhibiting depolarization
Pharmacodynamics/Kinetics
Onset of action:
Infants ≥3 months and Children: 30 seconds to 1 minute
Adults: Good intubation conditions within 1 to 2 minutes (depending on dose administered); maximum neuromuscular
blockade within 4 minutes
Duration:
Infants: 3 to 12 months: 40 minutes
Children: 1 to 12 years: 26 to 30 minutes
Adults: ~30 minutes (with standard doses, increases with higher doses and inhalational anesthetic agents)
Distribution: Vd:
Children: 0.21 to 0.3 L/kg
Adults: 0.22 to 0.26 L/kg
Hepatic dysfunction: 0.53 L/kg
Renal dysfunction: 0.34 L/kg
Protein binding: ~30%
Metabolism: Minimally hepatic; 17-desacetylrocuronium (5% to 10% activity of parent drug)
Half-life elimination:
Alpha elimination: 1 to 2 minutes
Beta elimination:
Infants 3 to 12 months: 1.3 ± 0.5 hours
Children 1 to <3 years: 1.1 ± 0.7 hours
Children 3 to <8 years: 0.8 ± 0.3 hours
Adults: 1.4 to 2.4 hours
Hepatic impairment: 4.3 hours
Renal impairment: 2.4 hours
Excretion: Feces (31%); urine (26%) (Proost 2000)
Clearance: Pediatric patients:
Infants 3 to <12 months: 0.35 L/kg/hour
Children 1 to <3 years: 0.32 L/kg/hour
Children 3 to <8 years: 0.44 L/kg/hour

INDICATIONS: Neuromuscular blockade: As an adjunct to general anesthesia to facilitate rapid sequence and routine
tracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation

ADVERSE REACTIONS
Frequency not always defined.
Cardiovascular: Increased peripheral vascular resistance (abdominal aortic surgery: 24%, frequency not defined during
other procedures), tachycardia (≤5%; incidence greater in children), hypertension, transient hypotension
Hypersensitivity: Anaphylaxis
<1%, postmarketing, and/or case reports: Anaphylactoid reaction, asthma, cardiac arrhythmia, ECG abnormality, edema
at insertion site, hiccups, nausea, pruritus, skin rash, vomiting

VECURONIO
DOSING

Dosing: Adult
Dose to effect; doses will vary due to interpatient variability.
Surgical relaxation: IV (do not administer IM):
Tracheal intubation: IV: Initial: 0.08-0.1 mg/kg. Note: If intubation is performed using succinylcholine (not preferred agent
in pediatric patients), the initial dose of vecuronium may be reduced to 0.04-0.06 mg/kg with inhalation anesthesia and
0.05-0.06 mg/kg with balanced anesthesia.
Obesity: For obese (≥130% of IBW) adult patients, may use ideal body weight (IBW) (Erstad, 2004; Schwartz, 1992;
Weinstein, 1988); onset time may be slightly delayed using IBW.
Pretreatment/priming: Adults: 10% of intubating dose given 3-5 minutes before intubating dose
Maintenance for continued surgical relaxation (only after return of neuromuscular function): Intermittent dosing: 0.01-0.015
mg/kg or continuous infusion of 0.8-1.2 mcg/kg/minute (0.048-0.072 mg/kg/hour).
Note: Use lower end of the dosing range when anesthesia is maintained with an inhaled anesthetic agent, with the
redosing interval guided by monitoring with a peripheral nerve stimulator.
ICU paralysis (eg, facilitate mechanical ventilation) in selected adequately sedated patients (Darrah, 1989; Greenberg,
2013; Murray, 2002; Rudis, 1997): IV: Initial bolus dose: 0.08-0.1 mg/kg, then a continuous IV infusion of 0.8-1.7
mcg/kg/minute (0.048-0.102 mg/kg/hour); monitor depth of blockade every 1-2 hours initially until stable dose, then every
8-12 hours. Usual maintenance infusion dose range: 0.8-1.2 mcg/kg/minute (0.048-0.072 mg/kg/hour).
Dosage adjustment (Rudis, 1996; Rudis, 1997): Adjust rate of administration in increments of 0.3 mcg/kg/minute (or 0.018
mg/kg/hour) or by 50% reductions of previous dose according to peripheral nerve stimulation response or desired clinical
response. Discontinue infusion if neuromuscular function does not return.
Note: When possible, minimize depth and duration of paralysis. Stopping the infusion daily for some time until forced to
restart based on patient condition is recommended to reduce post-paralytic complications (eg, acute quadriplegic
myopathy syndrome [AQMS]) (Murray, 2002; Segredo, 1992).
Intermittent bolus dosing (Hunter, 1985): 0.1-0.2 mg/kg/dose; may be repeated when neuromuscular function returns
Control of refractory shivering in adequately sedated patients during therapeutic hypothermia after cardiac arrest (off-label
use; Bernard, 2002; Nolan, 2003; Polderman, 2009): IV: 8-12 mg; redose as needed to control shivering. Note: Duration
of action prolonged in hypothermic patients. May mask seizure activity.

CLINICAL PHARMACOLOGY:

Mechanism of Action
Blocks acetylcholine from binding to receptors on motor endplate inhibiting depolarization
Pharmacodynamics/Kinetics
Onset of action:
Good intubation conditions: Within 2.5-3 minutes
Maximum neuromuscular blockade: Within 3-5 minutes
Duration: Under balanced anesthesia (time to recovery to 25% of control): 25-40 minutes; recovery 95% complete ~45-65
minutes after injection of intubating dose
Distribution: Vd: 0.3-0.4 L/kg
Protein binding: 60% to 80%
Metabolism: Active metabolite: 3-desacetyl vecuronium (1/2 the activity of parent drug)
Half-life, elimination:
Infants: 65 minutes
Children: 41 minutes
Healthy adult surgical patients and renal failure patients undergoing transplant surgery: 65-75 minutes; Late pregnancy:
35-40 minutes
Half-life, distribution: Adults: 4 minutes
Excretion: Primarily feces (40% to 75%); urine (30% as unchanged drug and metabolites); the rate of elimination is
appreciably reduced with hepatic dysfunction but not with renal dysfunction

INDICATIONS Use: Labeled Indications

To facilitate endotracheal intubation and to relax skeletal muscles during surgery; to facilitate mechanical ventilation in
ICU patients; does not relieve pain or produce sedation

ADVERSE REACTIONS
<1%, postmarketing, and/or case reports: Bradycardia, circulatory shock, edema, flushing, hypersensitivity reaction
(including erythema, hypotension, tachycardia, urticaria), pruritus, skin rash