Paralytic Agents for RSI: Fun Facts

Posting on behalf of Prof Tiru who found this:

Emergency Physicians regularly use neuromuscular blocking agents for rapid sequence intubation. It is not uncommon to wonder why a specific patient seems to respond with inadequate paralysis or an extended duration of neuromuscular blockade. Some pearls regarding the use of nondepolarizing agents:
  • Hypercalcemia decreases duration of blockade.
  • Hypermagnesemia prolongs the duration of action.
  • Hypothermia can prolong the duration of action.
  • Hypokalemia may augment the blockade.
  • Acidosis enhances the blockade effect.
  • Aminoglycosides are known to prolong the duration of action.
  • Patients chronically on phenytoin/carbamazepine exhibit resistance to rocuronium.
  • Severe hepatic dysfunction prolongs rocuronium's effect. However, renal failure does not affect the duration of single doses.
References:
(1) Greenberg SB, et al. Crit Care Med 2013;41:1332-44.
(2) Warr J, et al. Ann Pharmacother 2011;45:1116-1126.