Intravenous Neuromuscular Blocking Agents Physicochemical and Pharmacokinetic Characteristics

Drug	Onset (min)	Log D	Protein Binding (%)	Metabolism / Elimination	Dose Adjustment on ECMO^	Dose Range*


Atracurium	3–5	-3.98	~37	Ester hydrolysis and Hofmann elimination	-	Adult: 4–20 mcg/kg/min Pediatric: 5–40 mcg/kg/min Neonatal: 5–40 mcg/kg/min
Cisatracurium	3–5	-3.73	~38	Hofmann elimination	-	Adult: 0.5–10 mcg/kg/min Pediatric: 0.5–10 mcg/kg/min Neonatal: 0.5–10 mcg/kg/min
Mivacurium	2–3	-2.5	~30	Plasma cholinesterase	-	Adult: 5–10 mcg/kg/min Pediatric: 6–25 mcg/kg/min Neonatal: 6–25 mcg/kg/min
Pancuronium	2–5	Not available	~87	Renal / Hepatic	-	Adult: 0.8–1.7 mcg/kg/min Pediatric: 0.8–2 mcg/kg/min Neonatal: 0.8–2 mcg/kg/min
Rocuronium	1–2	-1.68	~46	Hepatic	-	Adult: 3–16 mcg/kg/min Pediatric: 5–17 mcg/kg/min Neonatal: 5–17 mcg/kg/min
Vecuronium	2–4	-0.75	60–80	Hepatic / Renal	-	Adult: 0.8–1.7 mcg/kg/min Pediatric: 0.8–2.5 mcg/kg/min Neonatal: 0.8–2.5 mcg/kg/min

- Minimal sequestration; no need for dose adjustment

++ Moderate sequestration; may require dose adjustment

+++ Significant sequestration; need for dose adjustment

^Based on hydrophilic properties neuromuscular blocking agents are expected to exhibit minimal sequestration within the ECMO circuiy. However, critical illness and resuscitation strategies may affect the volume of distribution and clearance.

*Titrate to patient-specific goals, using the lowest effective dose. Dose ranges represent doses typically used in clinical practice; in some situations, patients may require doses above the usual dose range to achieve patient-specific goals. Ensure adequate pain control and deep sedation prior to and during administration of neuromuscular blocking agents.