Usual Adult Dose for Anesthesia

TRACHEAL INTUBATION:

• Initial dose: 0.6 mg/kg IV
• An 80% block or greater is attained in a time of 1 (0.4 to 6) minute(s) and most patients have intubation completed within 2 minutes.
• Maximum blockade is achieved in most patients in less than 3 minutes.
• This dose may be expected to provide 31 (15 to 85) minutes of relaxation under opioid/nitrous oxide/oxygen anesthesia (under halothane, isoflurane, and enflurane anesthesia, some extension of the period of relaxation should be expected).

OR
Alternatively, a lower dose (0.45 mg/kg) may be used. An 80% block or greater is attained in a time of 1.3 (0.8 to 6.2) minute(s), and most patients have intubation completed within 2 minutes. Maximum blockade is achieved in most patients in less than 4 minutes. This dose may be expected to provide 22 (12 to 31) minutes of relaxation under opioid/nitrous oxide/oxygen anesthesia. Patients receiving this low dose of 0.45 mg/kg who achieve less than 90% block (about 16% of these patients) may have a more rapid time to 25% recovery, 12 to 15 minutes.
OR
A large bolus dose of 0.9 or 1.2 mg/kg can be administered under opioid/nitrous oxide/oxygen anesthesia without adverse effects to the cardiovascular system.

RAPID SEQUENCE INTUBATION:

• In premedicated and anesthetized patients, 0.6 to 1.2 mg/kg will provide adequate intubating conditions in most patients in less than 2 minutes.

MAINTENANCE DOSING:

• Maintenance doses of 0.1, 0.15, and 0.2 mg/kg administered at 25% recovery of control T1 (defined as 3 twitches of train-of-four), provide a median of 12 (2 to 31), 17 (6 to 50), and 24 (7 to 69) minutes of duration under opioid/nitrous oxide/oxygen anesthesia.
• Dosing should be guided based on the duration following initial dose or prior maintenance dose and not administered until recovery of neuromuscular function is evident.
• An insignificant cumulation of effect with repetitive maintenance dosing has been observed.

CONTINUOUS INFUSION:

• An initial rate of 10 to 12 mcg/kg/min should be initiated only after early evidence of spontaneous recovery from an intubating dose.
• Due to rapid redistribution and the associated rapid spontaneous recovery, initiation of the infusion after substantial return of neuromuscular function (more than 10% of control T1) may necessitate additional bolus doses to maintain adequate block for surgery.
• Upon reaching the desired level of neuromuscular block, the infusion should be individualized.
• The rate of administration should be adjusted according to the twitch response (as monitored with the use of a peripheral nerve stimulator).
• Infusion rates have ranged from 4 to 16 mcg/kg/min.
• Inhalation anesthetics (e.g., enflurane, isoflurane) may enhance the neuromuscular blocking action of nondepolarizing muscle relaxants.
• In the presence of steady-state concentrations of enflurane or isoflurane, it may be necessary to reduce the rate of infusion by 30% to 50%, at 45 to 60 minutes after the intubating dose.
• In obese patients, the initial dose of this drug should be based upon the patient's actual body weight.

Comments:

• Dosing information is derived from studies based upon units of drug per unit of body weight. It is intended to serve as an initial guide to clinicians familiar with other neuromuscular blocking agents to acquire experience with this drug. More information may be obtained by consulting the manufacturer product information.
• As with other neuromuscular blocking agents, the dosage of this drug should be individualized in each patient. The method of anesthesia, expected duration of surgery, method of sedation, expected duration of mechanical ventilation, possible interaction with other drugs that are administered concomitantly, and the condition of the patient should be taken into account when determining the dose.
• The use of an appropriate neuromuscular monitoring technique is recommended for the evaluation of neuromuscular block and recovery.

Use: For inpatients and outpatients as an adjunct to general anesthesia to facilitate both rapid sequence and routine tracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation.

Usual Pediatric Dose for Anesthesia

INFANTS AND CHILDREN:
TRACHEAL INTUBATION: 0.45 to 0.6 mg/kg IV depending on anesthetic technique and the age of the patient should produce good intubating conditions within 75 seconds when used with sevoflurane; when halothane is used, a 0.6 mg/kg dose resulted in excellent to good intubating conditions within 60 seconds.

• The time to maximum block for an intubating dose is shortest in infants (28 days up to 3 months) and longest in neonates (birth to less than 28 days). The duration of relaxation following an intubating dose is shortest in children (greater than 2 years up to 11 years) and longest in infants.
• When sevoflurane is used for induction and isoflurane/nitrous oxide for maintenance of general anesthesia, maintenance dosing can be administered as bolus doses of 0.15 mg/kg at reappearance of T3 in all pediatric age groups.
• Maintenance dosing can also be administered at the reappearance of T2 at a rate of 7 to 10 mcg/kg/min, with the lowest dose requirement for neonates (birth to less than 28 days) and the highest dose requirement for children (greater than 2 years up to 11 years).
• When halothane is used for general anesthesia, patients ranging from 3 months old through adolescence can be administered doses of 0.075 to 0.125 mg/kg upon return of T1 to 0.25% to provide clinical relaxation for 7 to 10 minutes; alternatively, a continuous infusion initiated at a rate of 12 mcg/kg/min upon return of T1 to 10% (one twitch present in train-of-four) may also be used to maintain neuromuscular blockade in pediatric patients.

Comments:

• Dosing information is derived from studies based upon units of drug per unit of body weight. It is intended to serve as an initial guide to clinicians familiar with other neuromuscular blocking agents to acquire experience with this drug. More information may be obtained by consulting the manufacturer product information.
• As with other neuromuscular blocking agents, the dosage of this drug should be individualized in each patient. The method of anesthesia, expected duration of surgery, method of sedation, expected duration of mechanical ventilation, possible interaction with other drugs that are administered concomitantly, and the condition of the patient should be taken into account when determining the dose.
• The use of a neuromuscular monitoring technique is recommended for the evaluation of neuromuscular block and recovery.
• The experience with this drug in rapid sequence induction in pediatric patients is limited. This drug is therefore not recommended for facilitating tracheal intubation conditions during rapid sequence induction in pediatric patients.

Use: For tracheal intubation during routine sequence induction

Renal Dose Adjustments

No adjustment recommended.

Liver Dose Adjustments

Caution recommended.

Precautions

CONTRAINDICATIONS:

• Hypersensitivity to the active component or any of the ingredients
• Hypersensitivity to other neuromuscular blocking agents

Consult WARNINGS section for additional precautions.

Dialysis

Data not available

Other Comments

General:

• This drug should only be administered by experienced clinicians or trained individuals supervised by an experienced clinician familiar with the use, actions, characteristics, and complications of neuromuscular blocking agents. Doses should be individualized and a peripheral nerve stimulator should be used to monitor drug effect, need for additional doses, adequacy of spontaneous recovery or antagonism, and to decrease the complications of overdosage if additional doses are administered.
• This drug, which has an acid pH, should not be mixed with alkaline solutions (e.g., barbiturate solutions) in the same syringe or administered simultaneously during intravenous infusion through the same needle.
• If extravasation occurs, it may be associated with signs or symptoms of local irritation. The injection or infusion should be terminated immediately and restarted in another vein.