Version May 2024
| Agent | Vecuronium | Rocuronium | Pancuronium* | Mivacurium¶ | Atracurium | Cisatracurium | Succinylcholine |
| Type (structure) | Non-depolarizing | Non-depolarizing | Non-depolarizing | Non-depolarizing | Non-depolarizing | Non-depolarizing | Depolarizing |
| Type (duration) | Intermediate | Intermediate | Long | Short | Intermediate | Intermediate | Ultrashort |
| Potency – ED95 (mg/kg) | 0.04 | 0.3 | 0.07 | 0.08 | 0.21 | 0.04 to 0.05 | 0.25 to 0.3 |
| Intubating dose (mg/kg) | 0.1 to 0.2Δ | 0.6 to 1 (1.2 with RSII dose)◊ | 0.08 to 0.12 | 0.2 | 0.5 to 0.6 | 0.15 to 0.2§ | 0.6 to 1.5 |
| Onset time (min) | 3 to 4 | 1 to 2 | 2 to 3 | 3 to 4 | 3 to 5 | 4 to 6 | 1 |
| Time to 25% recovery (min) | 20 to 35 | 30 to 50 (60 to 80 with RSII dose) | 60 to 120 | 15 to 20 | 20 to 35 | 30 to 60 | 5 to 10 |
| Elimination half-life (min) | |||||||
| 50 to 60 | 60 to 100 | 100 to 130 | 2 to 2.5 | 21 | 23 to 30 | <1 |
| Mild increase | 100 to 300 | Increased ×2 | 3 to 4 | 21 | Mild increase | <1 |
| Significant increase | 120 to 400 | Increased ×2 | 3 to 6 | 21 | 23 to 30 | <1 |
| Intermittent maintenance dose (mg/kg)¥ | 0.01 | 0.1 | 0.02 | 0.1 | 0.1 | 0.01 | N/A |
| Starting infusion dose (mcg/kg/min)‡ | 1 to 2 | 5 to 12 | Not recommended | 5 to 8 | 4 to 12 | 1 to 3 | |
| Elimination route/metabolism | Renal 10 to 50%; hepatic 30 to 50% | Renal 30%; hepatic 70% | Renal 40 to 70%; hepatic 20% | Plasma cholinesterase (70% of succinylcholine rate) | Renal 10%; Hoffman 30%; ester hydrolysis 60% | Hoffman 30%; ester hydrolysis 60% | Butyrylcholinesterase (plasma cholinesterase, pseudocholinesterase) |
| Active metabolites | 3-desacetyl-vecuronium | 17-desacetyl-rocuronium (minimal) | 3-OH-pancuronium; 17-OH-pancuronium | No active metabolites | No active metabolites | No active metabolites | No active metabolites |
| Side effects | Vagal blockade with large doses | Minimal | Vagal block (tachycardia), catecholamine release | Histamine release | Histamine release; laudanosine and acrylates production | None | Myalgia; bradycardia/ asystole in children or with repeated dosing; dual (phase II, competitive) block; anaphylaxis |
| Contraindications (other than specific allergy) | None | None | Short surgical procedures (<60 min); not recommended for continuous infusion | Pseudocholinesterase deficiency | Hemodynamically unstable patients due to histamine release | None | High K+; MH; muscular dystrophy; children; receptor up-regulation settings; pseudocholinesterase deficiency |
| Comments | Not for prolonged ICU administration (myopathy); reversible by sugammadex; elimination half-life halved in late pregnancy; 3-desacetyl metabolite has 60% of the parent compound potency | Pain on injection; easily reversible by sugammadex; elimination half-life prolonged in ICU patient; 17-desacetyl metabolite has 20% activity | Significant accumulation, prone to residual block (3-OH metabolite has 50% activity of pancuronium) | Reversal by cholinesterase inhibitors; mixture of 3 isomers (cis-cis minimal); edrophonium for antagonism more effective during deep block | Organ-independent elimination | Trivial histamine release; minimal plasma laudanosine and acrylate levels | Fastest onset, most reliable NMBA for rapid tracheal intubation |
ED95: effective dose to achieve 95% depression of baseline muscle contraction; ICU: intensive care unit; K+: potassium; MH: malignant hyperthermia; N/A: data not available; NMBA: neuromuscular blocking agents; RSII: rapid sequence induction and intubation; ST: single twitch.
* Pancuronium is no longer available in the United States, Canada, or Europe. It is available in several countries around the world.
¶ Mivacurium is no longer available in the United States or Canada. It is available in many other countries.
Δ Vecuronium at a dose of 0.1 to 0.2 mg/kg may be used for RSII in patients for whom succinylcholine is contraindicated and rocuronium is unavailable; onset of paralysis will be delayed compared with those preferred agents.
◊ Some experts use a higher dose, 1.5 mg/kg IV, of rocuronium for rapid sequence induction in the emergency department. Refer to UpToDate content on rapid sequence in duction for emergency intubation.
§ Cisatracurium at a dose of 0.4 mg/kg may be used for RSII in patients for whom succinylcholine is contraindicated and rocuronium is unavailable; onset of paralysis will be delayed compared with those preferred agents.
¥ Intermittent dosing titrated to endpoints such as ventilator synchrony may be preferred to continuous infusions in the ICU. Higher intermittent maintenance doses may be used in the ICU to provide a longer duration of action and to avoid continuous infusion.
‡ The starting infusion dose presumes that an intubating dose or a similar loading dose has been given prior to starting the infusion. The infusion dose should be adjusted thereafter based on monitoring.آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
