Review Article

Rocuronium Use in Neonate: A Review Study

Mohammed Abduh Alshafyie

MD, Pediatric Emergency Consultant, King Saudi Medical City, Riyadh, Saudi Arabia.

ABSTRACT
Neuromuscular blocking agents (NMBAs) are used in a range and side effects of these drugs, further research into their
of critical illnesses in neonates and infants, despite a lack of effects on neonatal physiology is needed.
guidelines and professional standards. This study reviewed the
current evidence base and practice regarding the continuous Keywords: Rocuronium, Neuromuscular Blocking Agents,
use of these agents in this age range. An online literature Muscle Relaxant, Neonate, Infant.
search for NMBA (Rocuronium) use in neonates was *Correspondence to:
performed using PubMed, MEDLINE and EMBASE. Mohammed Abduh Alshafyie,
The search terms used were Rocuronium, neuromuscular Pediatric Emergency Consultant,
block, muscle relaxant and neonate, infant, NICU. In King Saudi Medical City, Riyadh, Saudi Arabia.
conclusion there are some supportive data regarding short- Article History:
term efficacy of intermittent NMBA use in neonates, but the Received: 11-06-2018, Revised: 09-07-2018, Accepted: 31-07-2018
long-term effects remain unknown. Access this article online
However, while consensus statements and accepted standards Website:
Quick Response code
regarding NMBA use and assessment exist in both adult and [Link]
paediatric intensive care units, there seems to be limited
information available to guide those using NMBAs in neonatal DOI:
10.21276/ijmrp.2018.4.4.002
intensive care units (NICUs). Considering the possible toxicity

INTRODUCTION
The neuromuscular junction in humans develops in the second ventilation in preterm neonates leads to a higher incidence of
month gestation,1 Therefore, neuromuscular blocking agents pneumothorax5 and higher peak transpulmonary pressures6 and is
(NMBAs), or muscle relaxing drugs, are used when physicians likely to increase risk of intraventricular haemorrhage.7 Neonates
intubate neonates2 to assist difficult ventilation and to allow are relatively more sensitive to NMBAs effect than older children,
wound healing after surgery. Therefore they present longer action times8 and require smaller
NMBAs, are given to infants and children for anaesthesia to doses.9
provide muscle relaxation, to reduce the quantity of anaesthetic Neuromuscular blocking agent use is associated with
agent required and to facilitate controlled ventilation. There are complications, including prolonged blockade through over
different Factors affecting paediatric responses to neuromuscular dosage10, postventilation muscle weakness11, hypotension12 and
blocking drugs including Development of the neuromuscular hypoxaemia.13 Nevertheless, the early use of NMBAs in specific
system and Maturation of neuromuscular transmission.3 conditions has been shown to minimize the side effects.14
One of the NMBDs is Rocuronium a Non-depolarizing Inadequate sedation or anaesthesia can lead to awareness during
neuromuscular blocking drug that is used for adult and pediatrics. neuromuscular blockade in those undergoing procedures, clearly,
The clinically available non-depolarizing neuromuscular blocking neonates and infants cannot communicate such awareness, and
agents can be classified into benzylquinolinium or aminosteroidal particular vigilance is necessary.15 There are limited data available
compounds. Benzylquinolium drugs are associated with histamine regarding the safe use of NMBAs in neonates; in this study we
release and hypotension, whereas aminosteroidal (including reviewed all available data regarding current neonate NMBA use.
Rocuronium) compounds are associated with tachycardia and In reviewing three clinical trials about Rocuronium effect when
hypertension. Rocuronium is an analogue of vecuronium with a giving at 0.6 mg kg dose It produced adequate intubating
more rapid onset of action. Which is the result of reduced potency, conditions in 100% of children 60 s after injection. Concluding that
necessitating an increase in dose, and thus the injection of larger Rocuronium to be an acceptable alternative to succinylcholine for
dose.4 NMBAs can prevent dangerous neonate-ventilator rapid sequence induction after a careful assessment of the airway
asynchrony, such as in severe meconium aspiration syndrome to exclude possible difficulty with intubation. While higher doses of
with persistent pulmonary hypertension or in the presence 1–2 x ED95 of rocuronium produce a insignificant increase in
of an air leak. There is evidence that asynchronous mechanical heart rate with no change in arterial blood pressure.16

6|P a g e Int J Med Res Prof.2018 July; 4(4); 6-8. [Link]

A study conducted on Forty-four randomized (20 rocuronium, 24 chronological and corrected gestational age, weight and
controls) intubated full term and pre term infants similar in intubator’s experience. Succeeded intubation on first attempt in
chronological and corrected gestational age, weight and 35% of intubations under rocuronium vs. 8% of controls;
intubator’s experience. Succeeded intubation on first attempt in rocuronium. Complete paralysis was reported in 80% of 57
35% of intubations under rocuronium vs. 8% of controls; rocuronium intubations; onset ranged from 14 to 178 s, and
rocuronium. Complete paralysis was reported in 80% of 57 duration from 1 to 60 min.15 A study concluded that Rocuronium
rocuronium intubations; onset ranged from 14 to 178 s, and facilitated successful intubation and provided clinical paralysis
duration from 1 to 60 min.17 rapidly in most infants while other study has examined the effect
Another study has examined the effect of intermittent boluses of intermittent boluses feeding to be used depending on the
feeding to be used depending on the indications although first indications although first principles suggest that an infusion seems
principles suggest that an infusion seems appropriate to provide appropriate to provide continuous NMBA, but in reality, there is
continuous NMBA, but in reality, there is little evidence to support little evidence to support the use of continuous NMBA
the use of continuous NMBA administration in neonates, although administration in neonates, although this seems to be a commonly
this seems to be a commonly used mechanism of delivery, close used mechanism of delivery, close monitoring of efficacy seems
monitoring of efficacy seems warranted. Regardless of the mode warranted. Regardless of the mode of administration.8
of administration.3 In conclusion there are some supportive data regarding short-term
efficacy of intermittent NMBA use in neonates, but the long-term
METHODS effects remain unknown.16 However, while consensus statements
An online literature search for NMBA (Rocuronium) use in and accepted standards regarding NMBA use and assessment
neonates was performed using PubMed (to Jun 2018), MEDLINE exist in both adult and paediatric intensive care units, there seems
(from 1966 to June 2018), and EMBASE (from 1988 to June to be limited information available to guide those using NMBAs in
2018). The search terms used were Rocuronium, neuromuscular neonatal intensive care units (NICUs). Considering the possible
block, muscle relaxant and neonate, infant, NICU. toxicity and side effects of these drugs, further research into their
effects on neonatal physiology is needed.
DISCUSSION
There are limited data available regarding the safe use of NMBAs REFERENCES
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