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Rocuronium (Systemic)

Primary: MS300

Commonly used brand name(s): Zemuron.

Note: For a listing of dosage forms and brand names by country availability, see Dosage Forms section(s).


Neuromuscular blocking (paralyzing) agent—



Skeletal muscle paralysis—Rocuronium is indicated as an adjunct to general anesthesia to facilitate rapid-sequence or routine tracheal intubation and to induce skeletal muscle relaxation during surgery or mechanical ventilation {01} {02} {07} {11} {12} {13} {14} {15} {16} {23}.

Acceptance not established
Rocuronium has not been studied for long-term use in the intensive care unit (ICU). Prolonged paralysis and/or skeletal muscle weakness may occur with chronic use in the ICU {01}.


Physicochemical characteristics:

Chemical group—
    Aminosteroid compound {01}.
Molecular weight—
    Rocuronium bromide: 609.69 {06}

Mechanism of action/Effect:

Rocuronium is a nondepolarizing neuromuscular blocking agent with a rapid to intermediate onset of action, depending on dose, and with an intermediate duration of action {01}. Rocuronium produces neuromuscular blockade by competing with acetylcholine for cholinergic receptors at the motor end plate {01}.

Other actions/effects:

Rocuronium causes increases in heart rate of over 30% of baseline in some patients {01} {07}. While the etiology of the tachycardia is believed to be multifactorial, vagal blockade may contribute to tachycardia {01} {07}. Rocuronium is more likely than vecuronium but less likely than pancuronium to cause tachycardia. {01}

Rocuronium may cause histamine release. In a study of histamine release, 1 of 88 (1.1%) patients receiving rocuronium had clinically significant concentrations of histamine. In premarketing clinical trials, rocuronium administration was accompanied by clinical signs of histamine release (e.g., flushing, rash, or bronchospasm) in 9 of 1137 (0.8%) patients {01}. No clinical evidence of histamine release was observed in the 45 patients enrolled in one study designed to provoke histamine release by the rapid injection of rocuronium {08}.


Approximately 80% of the initial rocuronium dose is redistributed. As administration of rocuronium continues, tissue compartments fill. Within 4 to 8 hours, less rocuronium is redistributed away from the site of action, and the dosage requirement to maintain neuromuscular blockade via continuous infusion falls to about 20% of the initial infusion rate {01}.

Volume of distribution:

Adults with normal hepatic and renal function: 0.26 ± 0.03 L per kg of body weight (L/kg) {01}.

Adults with hepatic function impairment: 0.53 ± 0.14 L/kg {01} {09}.

Renal transplant patients (adults): 0.34 ± 0.11 L/kg {01}.

Geriatric patients (> 65 years of age): 0.22 ± 0.03 L/kg {01}.

Infants 3 to 12 months of age: 0.3 ± 0.04 L/kg {01}.

Children 1 to 3 years of age: 0.26 ± 0.06 L/kg {01}.

Children 3 to 8 years of age: 0.21 ± 0.03 L/kg {01}.

Protein binding:

Low (30%) {01}.


Deacetylated in the liver to 17-desacetyl-rocuronium, a metabolite believed to have little neuromuscular blocking activity {01}.



Rocuronium has a biphasic distribution. The rapid distribution half-life is 1 to 2 minutes, and the slower distribution half-life is 14 to 18 minutes {01}.


Adult and geriatric patients with normal hepatic function: 1.4 ± 0.04 hours during opioid–nitrous oxide–oxygen anesthesia and 2.4 ± 0.08 hours during isoflurane anesthesia {01}.

Adult and geriatric patients with hepatic function impairment: 4.3 ± 2.6 hours during isoflurane anesthesia {01}.

Renal transplant patients (adults): 2.4 ± 1.1 hours during isoflurane anesthesia {01} {10}.

Infants 3 to 12 months of age: 1.3 ± 0.5 hours during halothane anesthesia {01}.

Children 1 to 3 years of age: 1.1 ± 0.7 hours during halothane anesthesia {01}.

Children 3 to 8 years of age: 0.8 ± 0.3 hour during halothane anesthesia {01}.

Onset of action:

With doses of 0.6 mg rocuronium per kg of body weight administered over 5 seconds, effective intubating conditions are achieved within 60 to 70 seconds {01} {03} {11} {12} {13} {14} {15} {16}.

Note: Onset of action of rocuronium may be delayed in patients with conditions, such as cardiovascular disease and advanced age, associated with slowed circulation.

Time to peak effect:

The time to peak effect is dependent on dosage, the age of the patient, and the anesthetic administered concurrently. The median times to maximum block are given below.

Adults 18 to 64 years of age under opioid–nitrous oxide–oxygen anesthesia:

0.45 mg per kg of body weight (mg/kg): 3 (range, 1.3–8.2) minutes {01}.

0.6 mg/kg: 1.8 (range, 0.6–13) minutes {01}.

0.9 mg/kg: 1.4 (range, 0.8–6.2) minutes {01}.

1.2 mg/kg: 1 (range, 0.6–4.7) minute {01}.

Geriatric patients 65 years of age and older under opioid–nitrous oxide–oxygen anesthesia:

0.6 mg/kg: 3.7 (range, 1.3–11.3) minutes {01}.

0.9 mg/kg: 2.5 (range, 1.2–5) minutes {01}.

1.2 mg/kg: 1.3 (range, 1.2–4.7) minutes {01}.

Infants 3 months to 1 year of age under halothane anesthesia:

0.6 mg/kg: 0.8 (range, 0.3–3) minute {01}.

0.8 mg/kg: 0.7 (range, 0.5–0.8) minute {01}.

Children 1 to 12 years of age under halothane anesthesia:

0.6 mg/kg: 1 (range, 0.5–3.3) minute {01}.

0.8 mg/kg: 0.5 (range, 0.3–1) minute {01}.

Duration of action:

Duration of clinical effect (the time until spontaneous return of the twitch response to 25% of control value as determined using a peripheral nerve stimulator) is dependent on dosage:

Adults 18 to 64 years of age—

0.45 mg/kg—22 (range, 12–31) minutes {01}.

0.6 mg/kg—31 (range, 15–85) minutes {01}.

0.9 mg/kg—58 (range, 27–111) minutes {01}.

1.2 mg/kg—67 (range, 38–160) minutes {01}.

Geriatric patients 65 years of age and older—

0.6 mg/kg—46 (range, 22–73) minutes {01}.

0.9 mg/kg—62 (range, 49–75) minutes {01}.

1.2 mg/kg—94 (range, 64–138) minutes {01}.

Infants 3 months to 1 year of age—

0.6 mg/kg—41 (range, 24–68) minutes {01}.

0.8 mg/kg—40 (range, 27–70) minutes {01}.

Children 1 to 12 years of age—

0.6 mg/kg—26 (range, 17–39) minutes {01}.

0.8 mg/kg—30 (range, 17–56) minutes {01}.

Note: Median time to spontaneous recovery from 25 to 75% of the control value is 13 minutes in adults {01}.

    Biliary and renal {01} {17}.

Precautions to Consider


Studies have not been done to evaluate the carcinogenic or tumorigenic potential of rocuronium {01}.


No mutagenic effect was observed with the Ames test {01}. No chromosomal abnormalities were induced in cultured mammalian cells {01}. The micronucleus test did not suggest mutagenic potential {01}.

Studies have not been done {01}.

Rocuronium crosses the placenta {01} {04}. Adequate and well-controlled studies in humans have not been done {01}.

No teratogenic effects were seen in a teratogenicity study in rats at dosages of 0.3 mg per kg of body weight (mg/kg) {01}.

FDA Pregnancy Category B {01}.


Rocuronium was administered in doses of 0.6 mg/kg to 55 patients for rapid-sequence induction of anesthesia for cesarean section. Patients were also given thiopental at doses of 4 to 6 mg/kg {04}. Anesthesia was maintained with isoflurane and nitrous oxide in oxygen. No neonate had an Apgar score below seven at 5 minutes after birth {01} {04}. Neonatal blood (umbilical venous) concentrations of rocuronium were 18% of maternal levels {04}. Intubating conditions were poor or inadequate at 1 minute in four patients receiving 4 mg/kg of thiopental {01} {04}. Increasing the thiopental dose to 6 mg/kg improved intubating conditions; however, increasing the thiopental dose to improve intubating conditions is controversial and is not recommended due to an increased chance of central nervous system (CNS) depression in the neonate {01} {04} {05}. Rocuronium is not recommended for rapid-sequence induction in cesarean section patients {01}.


It is not known if rocuronium is distributed into breast milk. However, problems in humans have not been documented {01}.


Appropriate studies on the relationship of age to the effects of rocuronium have not been performed in infants up to 3 months of age. Rocuronium was studied in 228 pediatric patients 3 months to 12 years of age in preapproval clinical trials {01}. When halothane anesthesia was used without atropine pretreatment, a high incidence of tachycardia (exceeding 30% over baseline) was observed in patients given 0.6 to 0.8 mg/kg of rocuronium {01}. A smaller, transient increase in heart rate was observed in another study of pediatric patients {18}.

Compared with adults, children have increased clearance of rocuronium {01} {19}. Compared with older children, infants have a longer duration of paralysis after an intubating dose of rocuronium {42}.

Some pediatric patients have experienced tachycardia, increased blood pressure, and resistance to neuromuscular blockade when phenylephrine nose drops were administered after rocuronium {18}.


Appropriate studies performed to date have not demonstrated geriatrics-specific problems that would limit the usefulness of rocuronium in the elderly. However, geriatric patients may have a delayed onset of effect compared with other adult patients {01} {20}.

Geriatric patients have a slightly prolonged duration of clinical effect compared with other adult patients, perhaps due to age-related changes in renal and hepatic perfusion {01} {20} {21}. The rate of spontaneous recovery (25 to 75%) in geriatric patients is not different from that in other adults {01}.

Drug interactions and/or related problems
The following drug interactions and/or related problems have been selected on the basis of their potential clinical significance (possible mechanism in parentheses where appropriate)—not necessarily inclusive (» = major clinical significance):

Note: Combinations containing any of the following medications, depending on the amount present, may also interact with this medication.

» Aminoglycosides or
» Bacitracin or
» Colistin or
» Polymyxins or
» Sodium colistimethate or
Tetracyclines or
» Vancomycin    (neuromuscular blocking activity of these medications may be additive to that of rocuronium; prolongation of neuromuscular blocking activity is possible when these medications and rocuronium are used concurrently {01})

Aminophylline or
Theophylline    (resistance to neuromuscular blockade may occur; higher doses of rocuronium may be needed {45} {46})

» Anesthetics, inhalation, especially enflurane and isoflurane    (the neuromuscular blocking activity of inhalation anesthetics may be additive to that of rocuronium; median spontaneous recovery time is prolonged by enflurane and isoflurane, but not by halothane; the infusion rate of rocuronium should be reduced by 40% when it is used concurrently with enflurane or isoflurane; the use of rocuronium with other inhalation anesthetics has not been fully studied {01} {12} {24} {25} {26})

Atropine or
Hyoscyamine    (vagolytic activity of atropine and hyoscyamine may be additive or synergistic with the vagolytic activity of rocuronium; tachycardia has been observed when atropine or hyoscyamine was administered to patients with rocuronium-induced neuromuscular blockade; increased tachycardia also may occur with other anticholinergic drugs {07} {43})

» Magnesium salts    (magnesium in large doses [e.g., for management of toxemia of pregnancy] may cause enhancement of blockade {01})

Neuromuscular blocking agents, other    (the use of rocuronium with other nondepolarizing neuromuscular blocking agents has not been fully studied; interactions have been reported when other nondepolarizing neuromuscular blocking agents were used in succession {01})

    (the use of rocuronium with mivacurium results in synergistic activity {27})

    (the use of rocuronium before succinylcholine to reduce side effects of succinylcholine is not recommended by the manufacturer; however, studies suggest that the use of a subparalyzing dose of rocuronium before succinylcholine reduces fasciculations resulting from the use of succinylcholine {50} {51} {52}; the findings on using rocuronium to reduce myalgia from the use of succinylcholine are inconsistent {51} {52}; if rocuronium is used following use of succinylcholine, it should not be given until recovery from succinylcholine has been observed {01})

Phenylephrine    (resistance to neuromuscular blockade may occur, perhaps due to changes in perfusion of the muscle tissue; some pediatric patients receiving phenylephrine nose drops in conjunction with rocuronium experienced tachycardia {18})

Phenytoin    (resistance to neuromuscular blockade may occur with chronic phenytoin therapy, perhaps due to receptor up-regulation; diminished magnitude of blockade and shortened duration of blockade may occur {01} {22})

» Quinidine    (injection of quinidine during recovery from other neuromuscular blocking agents can cause recurrent paralysis; the same interaction is possible with rocuronium {01})

Medical considerations/Contraindications
The medical considerations/contraindications included have been selected on the basis of their potential clinical significance (reasons given in parentheses where appropriate)— not necessarily inclusive (» = major clinical significance).

Except under special circumstances, this medication should not be used when the following medical problem exists:
» Hypersensitivity to rocuronium bromide{01}
Risk-benefit should be considered when the following medical problems exist
Acid-base or electrolyte imbalance    (action of rocuronium may be altered; resistance or enhanced effects may occur {01})

Burns    (resistance to neuromuscular blocking agents may occur {01})

» Cachexia or debilitation    (profound neuromuscular block may occur {01})

Cardiovascular disease    (onset of action of rocuronium may be delayed in patients with conditions, such as cardiovascular disease, in which circulation is slowed {01})

    (in one study, seven of ten patients receiving rocuronium during and following coronary artery bypass surgery experienced transient increases [³ 30%] in pulmonary vascular resistance {01})

Hepatic function impairment    (duration of action may be prolonged as compared to patients with normal hepatic function {01} {09} {17} {44}; greater interpatient variability may be observed in patients with hepatic function impairment, necessitating close monitoring of twitch response {47})

» Neuromuscular diseases, such as myasthenia gravis or myasthenic syndrome    (profound effects may occur with small doses of rocuronium {01} {44})

Pulmonary hypertension or valvular heart disease    (rocuronium may be associated with increased pulmonary vascular resistance {01})

Renal function impairment    (duration of action may be prolonged as compared to patients with normal renal function; greater interpatient variability is observed in patients with renal function impairment, necessitating close monitoring of twitch response {01} {10} {28} {29})

Patient monitoring
The following may be especially important in patient monitoring (other tests may be warranted in some patients, depending on condition; » = major clinical significance):

Degree of neuromuscular blockade    (a peripheral nerve stimulator may be used to determine the adequacy of spontaneous recovery or antagonism; recovery from neuromuscular blockade also should be evaluated clinically by assessment of 5-second head lift, phonation, ventilation, and ability to protect upper airway {01})

Side/Adverse Effects

Note: It is not known whether rocuronium can precipitate malignant hyperthermia in susceptible humans {01}, although it is believed to be unlikely {48}. Malignant hyperthermia has not been reported with administration of rocuronium, nor did rocuronium precipitate malignant hyperthermia when tested in susceptible swine {01}. However, clinicians using rocuronium should be familiar with the signs, symptoms, and treatment of malignant hyperthermia {01}.

The following side/adverse effects have been selected on the basis of their potential clinical significance—not necessarily inclusive:

Those indicating need for medical attention
Incidence less frequent

Incidence rare
skin rash{01}
swelling at injection site{01}

Those indicating need for medical attention only if they continue or are bothersome
Incidence more frequent
Pain on injection{30}{31}

Incidence rare


Note: No cases of overdose with rocuronium have been reported. Management of rocuronium overdose is the same as management of overdose of the other neuromuscular blocking agents.

For specific information on the agents used in the management of rocuronium overdose, see:

   • Atropine in Anticholinergics/Antispasmodics (Systemic) monograph;
   • Edrophonium (Systemic) monograph;
   • Glycopyrrolate in Anticholinergics/Antispasmodics (Systemic) monograph;
   • Neostigmine in Antimyasthenics (Systemic) monograph; and/or
   • Pyridostigmine in Antimyasthenics (Systemic) monograph.
For more information on the management of overdose, contact a Poison Control Center (see Poison Control Center Listing ).

Clinical effects of overdose
The following effects have been selected on the basis of their potential clinical significance—not necessarily inclusive:
Acute effects
prolonged paralysis{01}

Treatment of overdose
The primary treatment consists of maintenance of a patent airway and controlled ventilation until recovery of neuromuscular function. After evidence of spontaneous recovery, further recovery may be facilitated by administration of an anticholinesterase agent (e.g., edrophonium, neostigmine, pyridostigmine) and an anticholinergic agent (e.g., atropine or glycopyrrolate). Use of a peripheral nerve stimulator to monitor recovery from paralysis is recommended {01}.

General Dosing Information
Rocuronium should be administered under the direct supervision of an experienced clinician familiar with the actions and potential complications of neuromuscular blocking agents {01}. Equipment and materials for endotracheal intubation, assisted or controlled ventilation, and oxygen therapy, and an agent for reversal should be immediately available {01}.

Rocuronium has no effect on consciousness or pain threshold. Therefore, when rocuronium is used, adequate analgesia and sedation should be administered {01}.

Doses must be individualized. The stated doses are to be used as a guideline. The degree of neuromuscular blockade should be monitored clinically and with a peripheral nerve stimulator {01}. While the use of a peripheral nerve stimulator can help monitor neuromuscular function, studies comparing the action of rocuronium at the vocal cords and at the adductor pollicis show that onset is quicker at the vocal cords, but maximum block achieved with a given dose is less intense at the vocal cords as compared to the adductor pollicis {01} {32} {33}. The diaphragm is more resistant to rocuronium than is the adductor pollicis {34}. Differences in the action of rocuronium at these locations should be considered when using a peripheral nerve stimulator to monitor drug effect. Relaxation of the vocal cords and diaphragm is more likely to determine intubating conditions than is the degree of block achieved at the adductor pollicis, the site measured with a peripheral nerve stimulator {35}.

Onset of action of rocuronium may be delayed in patients with conditions, such as cardiovascular disease and advanced age, associated with slowed circulation. More time should be allowed for onset of effect in these patients. Higher doses to facilitate more rapid onset should not be used since such doses will result in longer duration of action {01}.

In most clinical trials, the dose for obese patients was determined using actual body weight (ABW). In one study in which the dose for obese patients was determined by ideal body weight (IBW), the patients experienced longer time to maximum block, shorter clinical duration, and unsatisfactory intubating conditions. In obese patients, it is recommended that the dose be determined according to ABW {01}.

Extravasation of rocuronium may result in local irritation. If extravasation occurs, the injection or infusion should be terminated immediately and restarted in another vein {01}.

Injection of rocuronium prior to loss of consciousness is associated with severe, burning pain at the site of injection {30} when administered through a peripheral vein. Although some health care practitioners administer lidocaine prior to intravenous injection of rocuronium to attenuate this effect, this technique has not been tested by a controlled trial {30}. Generally, rocuronium should not be administered until loss of consciousness {30}.

Rocuronium is recommended for intravenous administration only {01}.

Reversal of rocuronium blockade should not be attempted until demonstration of some spontaneous recovery from neuromuscular blockade {01}. Reversal of rocuronium can be accomplished more rapidly with edrophonium than with neostigmine at a return to 25% of control {36} {37}. At a return to 10% of control, reversal of neuromuscular blockade is accomplished more completely and rapidly with neostigmine than with edrophonium {36} {37}.

Parenteral Dosage Forms


Usual adult dose
Skeletal muscle paralysis


For rapid sequence intubation—
Intravenous, 0.6–1.2 mg per kg of body weight {01}.

For tracheal intubation—
Intravenous, 0.6 mg per kg of body weight {01}.

Note: This dose results in blockade sufficient for intubation in one (range, 0.4–6) minute, allows intubation to be completed within two minutes, and achieves maximum blockade within three minutes {01} {13} {14} {15} {16}. A lower dose of 0.45 mg per kg of body weight may be used with a small prolongation of time to blockade sufficient for intubation (1.3 minutes) and of time to achievement of maximum blockade (within 4 minutes). With a dose of 0.45 mg per kg of body weight, intubation can still be accomplished in most patients within two minutes {01}. Doses of 0.9 and 1.2 mg per kg of body weight have been administered during surgery under opioid–nitrous oxide–oxygen anesthesia without adverse cardiovascular effects {01} {11}.
The use of a priming dose (i.e., administration of ten percent of the dose of rocuronium, followed three minutes later by the remaining ninety percent of the intubating dose) significantly shortened the onset time in one study {38}. However, the peripheral intravenous injection of priming doses into patients who are conscious can be expected to be associated with burning pain on injection {30}. Patients may experience sensations of weakness and difficulty in breathing after receiving a priming dose {49}.


Doses of 0.1, 0.15, and 0.2 mg per kg of body weight given when twitch response returns to twenty-five percent of the control value provide a median of twelve (range, 2–31), seventeen (range, 6–50), and twenty-four (range, 7–69) minutes, respectively, of clinical relaxation under opioid–nitrous oxide–oxygen anesthesia {01}. Additional maintenance doses should be guided by recovery of neuromuscular function following the initial dose and should not be administered until recovery of neuromuscular function is evident {01}.

Intravenous infusion—
0.01 to 0.012 mg per kg of body weight per minute after evidence of recovery from the intubating dose. Additional doses may be needed until steady-state has been achieved. The rate of the maintenance infusion must be individualized for each patient and should be guided by the patient's twitch response to peripheral stimulation. In clinical trials, satisfactory blockade was obtained with maintenance infusion rates of 0.004 to 0.016 mg per kg of body weight per minute {01}.

Usual pediatric dose
Skeletal muscle paralysis

Infants up to 3 months of age—Dosage has not been established.

Infants and children 3 months to 12 years of age—Intubation: Intravenous, 0.6 mg per kg of body weight.

Note: The median time to maximum blockade in pediatric patients is one (range, 0.5–3.3) minute. The intubating dose provides a median time of clinical relaxation of forty-one (range, 24–68) minutes in infants 3 months to 1 year of age and twenty-seven (range, 17–41) minutes in children 1 to 12 years of age {01}.

Intravenous—Doses of 0.075 to 0.125 mg per kg of body weight administered when twitch response returns to twenty-five percent of the control value to provide an additional seven to ten minutes of clinical relaxation {01}.

Intravenous infusion—0.012 mg per kg per minute administered when twitch response returns to ten percent of the control value {01}. The rate should be adjusted based on twitch response to peripheral nerve stimulation.

Usual geriatric dose
See Usual adult dose.

Note: Onset of action may be delayed in some geriatric patients. Geriatric patients exhibit a slightly prolonged duration of clinical effect {01}.

Strength(s) usually available

10 mg/mL (Rx) [Zemuron{01}]


10 mg/mL (Rx) [Zemuron]

Packaging and storage:
Store between 2 and 8 °C (36 and 46 °F) {01}. Protect from freezing {01}.

Preparation of dosage form:
Rocuronium is compatible with 0.9% sodium chloride injection, 5% dextrose in sodium chloride injection, 5% dextrose in water injection, lactated Ringers injection, and sterile water for injection {01}.

After reconstitution with one of the diluents listed above, rocuronium should be used within 24 hours. The prepared solution should be inspected for particulate matter and clarity before being administered to the patient and should be discarded if particulate matter is present. Prior to reconstitution, rocuronium should be used within 30 days after removal from refrigeration {01}.

Rocuronium is incompatible with alkaline solutions (e.g., barbiturate solutions) {01}. The immediate formation of a precipitate after sequential injection of thiopental and rocuronium through the same intravenous line has been reported, even with flushing of the line between injections {39} {40} {41}.

Revised: 12/14/1998

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  1. Meistelman C, Plaud B, Donati F. Rocuronium (ORG 9426) neuromuscular blockade at the adductor muscles of the larynx and adductor pollicis in humans. Can J Anaesth 1992; 39: 665-9.
  1. Cantineau JP, Porte F, d'Honneur G, et al. Neuromuscular effects of rocuronium on the diaphragm and adductor pollicis muscles in anesthetized patients. Anesthesiology 1994; 81: 585-90.
  1. Sparr HJ, Mitterschiffthaler G. Are only large doses of rocuronium an alternative to succinylcholine for rapid-sequence induction? [letter; comment]. Anesthesiology 1994; 80: 1411-2.
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  1. Panel comment, 5/96.
  1. Daller JA, Erstad B, Rosado E, Otto C, et al. Aminophylline antagonizes the neuromuscular blockade of pancuronium but not vecuronium. Crit Care Med 1991; 19: 983-5.
  1. Panel comment, 5/96.
  1. Panel comment, 5/96.
  1. Panel comment, 5/96.
  1. Harvey SC, Roland P, Bailey MK, et al. A randomized, double-blind comparison of rocuronium, d-tubocurarine, and “mini-dose” succinylcholine for preventing succinylcholine-induced muscle fasciculations. Anesth Analg 1998; 87: 719-22.
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