NEUROMUSCULAR BLOCKING DRUGS ›
l DRUG ACTION Suxamethonium acts by mimicking
acetylcholine at the neuromuscular junction but
hydrolysis is much slower than for acetylcholine;
depolarisation is therefore prolonged, resulting in
Neuromuscular blockade (short duration) during surgery
l UNLICENSED USE Doses of suxamethonium in BNF may
differ from those in product literature.
Should only be administered by, or under the direct
supervision of, personnel experienced in its use.
disease). major trauma . neurological disease involving
acute wasting of major muscle . personal or family history
of congenital myotonic disease . prolonged immobilisation
(risk of hyperkalaemia). severe burns
l CAUTIONS Cardiac disease . neuromuscular disease .raised
l INTERACTIONS → Appendix 1: suxamethonium
▶ Common or very common Arrhythmias . bradycardia (may
occur with repeated doses) . flushing . muscle contractions
involuntary . myoglobinaemia . myoglobinuria . post
SIDE-EFFECTS, FURTHER INFORMATION Premedication with
atropine reduces bradycardia associated with
l ALLERGY AND CROSS-SENSITIVITY Allergic cross-reactivity
between neuromuscular blocking drugs has been reported;
caution is advised in cases of hypersensitivity to these
l PREGNANCY Mildly prolonged maternal neuromuscular
l BREAST FEEDING Unlikely to be present in breast milk in
l HEPATIC IMPAIRMENT Manufacturer advises caution,
particularly in end stage hepatic failure (increased risk of
prolonged apnoea due to reduced hepatic synthesis of
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: solution for
▶ Suxamethonium chloride (Non-proprietary)
Suxamethonium chloride 50 mg per 1 ml Suxamethonium chloride
100mg/2ml solution for injection ampoules | 10 ampoule P £28.80–£50.00
▶ Anectine (Aspen Pharma Trading Ltd)
Suxamethonium chloride 50 mg per 1 ml Anectine 100mg/2ml
solution for injection ampoules | 5 ampoule P £3.57
NEUROMUSCULAR BLOCKING DRUGS ›
Non-depolarising neuromuscular blocking drugs should
only be administered by, or under direct supervision of,
personnel experienced in their use, with adequate
training in anaesthesia and airway management.
l CAUTIONS Burns (resistance can develop, increased doses
may be required). cardiovascular disease (reduce rate of
administration). electrolyte disturbances (response
unpredictable). fluid disturbances (response
unpredictable). hypothermia (activity prolonged, lower
doses required). myasthenia gravis (activity prolonged,
lower doses required). neuromuscular disorders (response
▶ Common or very common Flushing . hypotension
▶ Uncommon Bronchospasm . hypersensitivity . skin
▶ Rare or very rare Muscle weakness . myopathy (after
prolonged use in intensive care)
l ALLERGY AND CROSS-SENSITIVITY Allergic cross-reactivity
between neuromuscular blocking drugs has been reported;
caution is advised in cases of hypersensitivity to these
l PREGNANCY Non-depolarising neuromuscular blocking
drugs are highly ionised at physiological pH and are
therefore unlikely to cross the placenta in significant
l BREAST FEEDING Non-depolarising neuromuscular
blocking drugs are ionised at physiological pH and are
unlikely to be present in milk in significant amounts.
Breast-feeding may be resumed once the mother has
recovered from neuromuscular block.
Neuromuscular blockade (short to intermediate duration)
▶ INITIALLY BY INTRAVENOUS INJECTION
▶ Adult: Initially 300–600 micrograms/kg, then (by
intravenous injection) 100–200 micrograms/kg as
required, alternatively (by intravenous injection)
initially 300–600 micrograms/kg, followed by (by
intravenous infusion) 300–600 micrograms/kg/hour
Neuromuscular blockade during intensive care
▶ INITIALLY BY INTRAVENOUS INJECTION
▶ Adult: Initially 300–600 micrograms/kg, initial dose is
optional, then (by intravenous infusion)
270–1770 micrograms/kg/hour; (by intravenous
infusion) usual dose 650–780 micrograms/kg/hour
DOSES AT EXTREMES OF BODY-WEIGHT
▶ To avoid excessive dosage in obese patients, dose
should be calculated on the basis of ideal body-weight.
l INTERACTIONS → Appendix 1: neuromuscular blocking
BNF 78 Neuromuscular blockade 1337
▶ Rare or very rare Cardiac arrest. circulatory collapse . shock
SIDE-EFFECTS, FURTHER INFORMATION Hypotension, skin
flushing, and bronchospasm is associated with histamine
release. Manufacturer advises minimising effects of
histamine release by administering over 1 minute in
patients with cardiovascular disease or sensitivity to
l DIRECTIONS FOR ADMINISTRATION For intravenous infusion
(Tracrium®; Atracurium besilate injection, Hospira;
Atracurium injection/infusion, Genus), give continuously
in Glucose 5% or Sodium Chloride 0.9%; stability varies
with diluent; dilute requisite dose with infusion fluid to a
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Atracurium besilate (Non-proprietary)
Atracurium besilate 10 mg per 1 ml Atracurium besilate
250mg/25ml solution for injection vials | 1 vial P £16.50 (Hospital
▶ Tracrium (Aspen Pharma Trading Ltd)
Atracurium besilate 10 mg per 1 ml Tracrium 250mg/25ml solution
for injection vials | 2 vial P £25.81
Tracrium 25mg/2.5ml solution for injection ampoules | 5 ampoule P £8.28
Tracrium 50mg/5ml solution for injection ampoules | 5 ampoule P £15.02
Neuromuscular blockade (intermediate duration) during
▶ INITIALLY BY INTRAVENOUS INJECTION
▶ Adult: Initially 150 micrograms/kg, then (by
intravenous injection) maintenance 30 micrograms/kg
every 20 minutes, alternatively (by intravenous
infusion) initially 180 micrograms/kg/hour, then (by
intravenous infusion) maintenance
60–120 micrograms/kg/hour, maintenance dose
administered after stabilisation
Neuromuscular blockade (intermediate duration) during
▶ INITIALLY BY INTRAVENOUS INJECTION
▶ Adult: Initially 150 micrograms/kg, initial dose is
optional, then (by intravenous infusion)
180 micrograms/kg/hour, adjusted according to
response; (by intravenous infusion) usual dose
DOSES AT EXTREMES OF BODY-WEIGHT
▶ To avoid excessive dosage in obese patients, dose
should be calculated on the basis of ideal body-weight.
l INTERACTIONS → Appendix 1: neuromuscular blocking
▶ Common or very common Bradycardia
l DIRECTIONS FOR ADMINISTRATION For intravenous infusion
(Nimbex ®, Nimbex Forte ®), give continuously in Glucose
5% or Sodium Chloride 0.9%; solutions of 2 mg/mL and
5 mg/mL may be infused undiluted; alternatively dilute
with infusion fluid to a concentration of 0.1–2 mg/mL.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Cisatracurium (Non-proprietary)
Cisatracurium (as Cisatracurium besilate) 2 mg per
1 ml Cisatracurium besilate 20mg/10ml solution for injection
ampoules | 5 ampoule P £37.75 (Hospital only) |
5 ampoule P £32.09–£37.75 | 10 ampoule P £75.50
Cisatracurium (as Cisatracurium besilate) 5 mg per
▶ Nimbex (Aspen Pharma Trading Ltd)
Cisatracurium (as Cisatracurium besilate) 2 mg per 1 ml Nimbex
20mg/10ml solution for injection ampoules | 5 ampoule P £37.75
Cisatracurium (as Cisatracurium besilate) 5 mg per 1 ml Nimbex
Forte 150mg/30ml solution for injection vials | 1 vial P £31.09
Neuromuscular blockade (short duration) during surgery
▶ INITIALLY BY INTRAVENOUS INJECTION
▶ Adult: 70–250 micrograms/kg; (by intravenous
injection) maintenance 100 micrograms/kg every
15 minutes, alternatively (by intravenous infusion)
maintenance 8–10 micrograms/kg/minute, (by
intravenous infusion) adjusted in steps of
1 microgram/kg/minute every 3 minutes if required;
(by intravenous infusion) usual dose
DOSES AT EXTREMES OF BODY-WEIGHT
▶ To avoid excessive dosage in obese patients, dose
should be calculated on the basis of ideal body-weight.
l CAUTIONS Burns (low plasma cholinesterase activity; dose
l INTERACTIONS → Appendix 1: neuromuscular blocking
Dose adjustments Reduce dose in severe impairment.
Dose adjustments Clinical effect prolonged in renal
failure—reduce dose according to response.
l DIRECTIONS FOR ADMINISTRATION For intravenous
infusion, give continuously in Glucose 5% or Sodium
chloride 0.9%. Dilute to a concentration of
500 micrograms/mL; may also be given undiluted. Doses
up to 150 micrograms/kg may be given over 5–15 seconds,
higher doses should be given over 30 seconds. In asthma,
cardiovascular disease or in those sensitive to reduced
arterial blood pressure, give over 60 seconds.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Mivacron (Aspen Pharma Trading Ltd)
Mivacurium (as Mivacurium chloride) 2 mg per 1 ml Mivacron
10mg/5ml solution for injection ampoules | 5 ampoule P £13.95
Mivacron 20mg/10ml solution for injection ampoules | 5 ampoule P £22.57
1338 Anaesthesia adjuvants BNF 78
Neuromuscular blockade (long duration) during surgery
▶ Adult: Initially 100 micrograms/kg, then
Neuromuscular blockade (long duration) during intensive
▶ Adult: Initially 100 micrograms/kg, initial dose is
optional, then 60 micrograms/kg every 60–90 minutes
DOSES AT EXTREMES OF BODY-WEIGHT
▶ To avoid excessive dosage in obese patients, dose
should be calculated on the basis of ideal body-weight.
l INTERACTIONS → Appendix 1: neuromuscular blocking
l SIDE-EFFECTS Apnoea . arrhythmia . hypersalivation . increased cardiac output. miosis
SIDE-EFFECTS, FURTHER INFORMATION Pancuronium lacks
histamine-releasing effect, but vagolytic and
sympathomimetic effects can cause tachycardia.
l HEPATIC IMPAIRMENT Possibly slower onset, higher dose
requirement, and prolonged recovery time.
l RENAL IMPAIRMENT Use with caution; prolonged duration
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Pancuronium bromide (Non-proprietary)
Pancuronium bromide 2 mg per 1 ml Pancuronium bromide
4mg/2ml solution for injection ampoules | 10 ampoule P £50.00
Neuromuscular blockade (intermediate duration) during
▶ INITIALLY BY INTRAVENOUS INJECTION
▶ Adult: Initially 600 micrograms/kg; (by intravenous
injection) maintenance 150 micrograms/kg,
alternatively (by intravenous infusion) maintenance
300–600 micrograms/kg/hour, adjusted according to
▶ Elderly: Initially 600 micrograms/kg; (by intravenous
injection) maintenance 75–100 micrograms/kg,
alternatively (by intravenous infusion) maintenance up
to 400 micrograms/kg/hour, adjusted according to
Neuromuscular blockade (intermediate duration) during
▶ INITIALLY BY INTRAVENOUS INJECTION
▶ Adult: Initially 600 micrograms/kg, initial dose is
optional; (by intravenous infusion) maintenance
300–600 micrograms/kg/hour for first hour, then (by
intravenous infusion), adjusted according to response
DOSES AT EXTREMES OF BODY-WEIGHT
▶ To avoid excessive dosage in obese patients, dose
should be calculated on the basis of ideal body-weight.
l INTERACTIONS → Appendix 1: neuromuscular blocking
▶ Uncommon Procedural complications .tachycardia
▶ Rare or very rare Angioedema . circulatory collapse . face
oedema . malignant hyperthermia . paralysis . shock
Dose adjustments Reduce maintenance dose; prolonged
l DIRECTIONS FOR ADMINISTRATION For continuous
intravenous infusion or via drip tubing, may be diluted with
Glucose 5% or Sodium Chloride 0.9%.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Rocuronium bromide (Non-proprietary)
Rocuronium bromide 10 mg per 1 ml Rocuronium bromide
50mg/5ml solution for injection ampoules | 10 ampoule P £24.00
Rocuronium bromide 50mg/5ml solution for injection vials |
10 vial P £28.00–£36.50 | 10 vial P £28.00 (Hospital only)
▶ Esmeron (Merck Sharp & Dohme Ltd)
Rocuronium bromide 10 mg per 1 ml Esmeron 50mg/5ml solution
for injection vials | 10 vial P £28.92 (Hospital only)
Neuromuscular blockade reversal
Neuromuscular blockade reversal
such as pancuronium bromide but they prolong the action of
the depolarising neuromuscular blocking drug
minute of intravenous injection and its effects last for 20 to
30 minutes; a second dose may then be necessary.
Glycopyrronium bromide p. 1335 or alternatively atropine
sulfate p. 1334, given before or with neostigmine, prevent
bradycardia, excessive salivation, and other muscarinic
Other drugs for reversal of neuromuscular blockade
Sugammadex p. 1340 is a modified gamma cyclodextrin that
can be used for rapid reversal of neuromuscular blockade
induced by rocuronium bromide or vecuronium bromide. In
practice, sugammadex is used mainly for rapid reversal of
neuromuscular blockade in an emergency.
Neostigmine with glycopyrronium
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, neostigmine p. 1125, glycopyrronium
Reversal of non-depolarising neuromuscular blockade
▶ Adult: 1–2 mL, repeated if necessary, alternatively
0.02 mL/kilogram, repeated if necessary; maximum
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