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.Do you want to add Medilib to your home screen?