Эсмерон®

General characteristics. Structure:

Active ingredient: 10 mg a bromide rokuroniya in 1 ml of solution.

Pharmacological properties:

Pharmacodynamics. Not depolarizing muscle relaxant of peripheral action. Action mechanism. Эсмерон® (a rokuroniya bromide) - the high-speed, not depolarizing muscle relaxant of average duration of action having all pharmacological effects (kurarepodobny), characteristic of this class of drugs. It blocks N-holinoretseptory of a skeletal muscle and interferes with the depolarizing action of acetylcholine. Antagonists of this action are acetylcholinesterase inhibitors like neostigmin of methylsulphonate, an edrofoniya of chloride and pyridostigmine of bromide.

Pharmakodinamichesky effects. ED90 (the dose necessary for suppression for 90% of sokratitelny reaction of a muscle of a thumb of a hand in response to stimulation of an elbow nerve) at intravenous general anesthesia makes about 0,3 mg/kg a bromide rokuroniya. ED95 at babies is lower, than at adults and children (0,25; 0,35 and 0,40 mg/kg, respectively).

The clinical duration of action (time before spontaneous recovery of sokratitelny ability of skeletal muscles to 25% of reference level) at a dose of 0,6 mg/kg a rokuroniya of bromide makes 30-40 minutes. The general duration (time before spontaneous recovery of sokratitelny ability of skeletal muscles to 90% of reference level) makes 50 minutes. The average time of spontaneous recovery of sokratitelny ability of skeletal muscles from 25% to 75% of reference level (a recovery index) after a bolyusny dose of 0,6 mg/kg a rokuroniya of bromide is equal to 14 minutes. At lower doses of 0,3-0,45 mg/kg the bromide rokuroniya (1-1.5 × ED90) beginning of action comes later and duration of action is shorter. At high doses of 2 mg/kg a bromide rokuroniya clinical duration makes 110 minutes.

Trachea intubation when carrying out planned anesthesia. Within 60 seconds after intravenous administration of 0,6 mg/kg a bromide rokuroniya (2 × ED90 at intravenous general anesthesia) practically at all patients adequate conditions for an intubation are reached, and at 80% from them conditions for an intubation are regarded as excellent. The general relaxation of skeletal muscles adequate for any surgical interventions, develops within 2 minutes. After introduction of 0,45 mg/kg a bromide rokuroniya, acceptable conditions for an intubation are created in 90 seconds.

Bystry successive induction of anesthesia. At bystry successive induction of anesthesia using a propofol or fentanyl/thiopental of sodium adequate conditions for an intubation are reached in 60 seconds at 93% and 96% of patients, respectively, after introduction of 1,0 mg/kg a bromide rokuroniya. From them, at 70% of patients they are estimated as excellent. The clinical duration of action a bromide rokuroniya at this dose makes about 1 hour then neuromuscular conductivity can be recovered. After introduction of a dose of 0,6 mg/kg a bromide rokuroniya adequate conditions for an intubation are reached in 60 seconds at 81% and 75% of patients when carrying out bystry successive induction of anesthesia with propofoly or sodium fentanyl/thiopental, respectively.

Special groups of patients. The average time of the beginning of action at babies and children at an intubation dose of 0,6 mg/kg a rokuroniya of bromide is a little shorter, than at adults. Duration of action and time of recovery of neuromuscular conductivity can be shorter at children in comparison with babies and adults.

Rokuroniya of bromide patients of senile age can have duration of action of maintenance doses (0,15 mg/kg) slightly more and at patients with a disease of a liver and/or kidneys (about 20 minutes) when using anesthesia enflurany and izoflurany, than at patients without disturbance of functions of excretory bodies at intravenous anesthesia (about 13 minutes). At repeated introduction of maintenance doses at the recommended level the cumulative effect (progressive increase in duration of action) was not observed.

Intensive care unit. After continuous infusion a bromide rokuroniya in intensive care unit time of recovery of train-of-four (TOF) - the relation (a ratio of sizes of the fourth and first responses of a muscle to four-digit (TOF) stimulation) to 0,7 depends on blockade level at the end of infusion. After continuous infusion within 20 hours or more average time (range) between repeated emergence of T2 (the second answer of a muscle) in response to TOF stimulation and recovery of the TOF relation to 0,7 approximately makes 1,5 (1-5) hours at patients without multiorgan insufficiency and 4 (1-25) hours at patients with multiorgan insufficiency.

Cardiovascular surgery. At patients to whom carrying out operation on heart is planned the most frequent effects from cardiovascular system observed during development of the maximum block after introduction of 0,6-0,9 mg/kg of the drug Esmeron® are the weak and clinically not expressed increase in ChSS - to 9% and increase in the average ABP - to 16% of reference levels.

Recovery of neuromuscular conductivity. Administration of inhibitors of acetylcholinesterase (неостигмин, pyridostigmine or edrofoniya) at repeated emergence of T2 or at the first signs of clinical recovery leads to recovery of neuromuscular conductivity after the block called by effect of the drug Esmeron®.

Pharmacokinetics. After intravenous administration of a single bolyusny dose the bromide rokuroniya change of its concentration in a blood plasma passes three exponential phases. At healthy adults average T1/2 (95% a confidence interval) makes 73 (66-80) minutes, (seeming) Vd in equilibrium conditions makes 203 (193-214) ml/kg. The clearance of plasma makes 3,7 (3,5-3,9) ml/kg/min.

In controlled researches it is shown that the clearance of plasma at patients of senile age and at patients with a renal failure is slowed down, however in the majority of researches observed distinctions did not reach the statistical importance. Vd at patients with diseases of a liver increases on average for 30 minutes, the clearance decreases by 1 ml/kg/min.

At babies (from 3 months to 1 year) the seeming Vd in equilibrium conditions is increased in comparison with adults and children (1-8 years). At children of 3-8 years the tendency to increase in clearance and shortening of T1/2 (about 20 minutes) in comparison with adults, children (1-3 years) and babies is observed. At introduction a bromide rokuroniya in the form of continuous infusion for simplification of carrying out artificial ventilation of the lungs within 20 hours or more, average T1/2 and the average (seeming) distribution volume in an equilibrium state a rokuroniya of bromide increase. In controlled clinical trials the expressed interindividual variability of indicators connected with various genesis and degree of manifestation was established (weed) organ insufficiency and individual characteristics of the patient. At patients with multiorgan insufficiency average (±SD) T1/2 made 21,5 (±3,3) hours, (seeming) Vd in an equilibrium state - 1,5 (±0,8) l/kg and clearance of plasma - 2,1 (±0,8) ml/kg/min.

Rokuroniya bromide is brought with urine and bile. Excretion with urine reaches 40% within 12-24 hours. After an injection marked radioactive isotope the bromide rokuroniya, its excretion averaged 47% with urine and 43% with a stake within 9 days. About 50% of drug are removed in not changed look.

Indications to use:

— for simplification of an intubation of a trachea when carrying out planned surgical interventions and bystry successive induction of anesthesia and for providing a relaxation of skeletal muscles during surgical interventions of various character at adults;

— for simplification of an intubation of a trachea when carrying out planned surgical interventions and for providing a relaxation of skeletal muscles during surgical interventions of various character at children since 1 month;

— for simplification of an intubation of a trachea when carrying out artificial ventilation of the lungs in intensive care units at adults (except children and patients of advanced age).

Route of administration and doses:

Эсмерон® it is entered intravenously both in the form of a bolyusny injection, and in the form of continuous infusion (see. "Compatibility when mixing with other medicines").

As well as in case of use of other muscle relaxants, Esmeron® it has to be entered only by experienced clinical physicians who are familiar with action of muscle relaxants, or under their observation.

The drug Esmeron® dose, as well as in case of use of other muscle relaxants, needs to be selected individually for each patient. At selection of a dose it is necessary to take into account a method of anesthesia and estimated duration of operation, a method of sedation and the expected duration of mechanical ventilation, possible interaction with others, jointly appointed, drugs, and also the general condition of the patient.

For assessment of degree of the neuromuscular block and recovery of neuromuscular conductivity it is recommended to use the corresponding methods of neuromuscular monitoring.

Inhalation anesthetics strengthen the neuromuscular block called by the drug Esmeron®. This strengthening, however, becomes clinically significant only when in the course of the general anesthesia concentration of volatiles in fabrics reaches the level sufficient for such interaction. Therefore, selection of doses of the drug Esmeron® should be carried out by introduction of lower maintenance doses through longer intervals or using lower speeds of infusion of the drug Esmeron® during long (more than 1 hour) the procedures which are held with use of an inhalation anesthesia (see. "Interaction with other medicines and other forms of interactions").

At adult patients as the general scheme when carrying out an endotracheal intubation and for providing a muscular relaxation at operations of various duration and for use in intensive care unit the following doses can be recommended.

At surgical interventions. Endotracheal intubation. The standard dose a bromide rokuroniya for carrying out an endotracheal intubation during usual anesthesia makes 0,6 mg/kg after which adequate conditions for an intubation of a trachea develop approximately in 60 seconds at most of patients. When carrying out bystry successive induction of anesthesia for simplification of conditions of an intubation of a trachea the recommended dose makes 1,0 mg/kg a bromide rokuroniya. In this case adequate conditions for an intubation of a trachea develop in 60 seconds almost at all patients. When using a dose of 0,6 mg/kg the bromide rokuroniya for carrying out bystry successive induction of anesthesia is recommended to carry out an intubation of a trachea of the patient in 90 seconds after administration of drug.

Information concerning use a bromide rokuroniya during bystry successive induction of anesthesia at patients to whom Cesarean section is carried out is specified in the section "Use at Pregnancy and a Lactation".

High doses. The choice of higher dose has to be reasonable at each specific patient. It is noted that introduction of initial doses to 2 mg/kg a bromide rokuroniya when carrying out surgeries proceeded without side effects from cardiovascular system. Use of these doses the rokuroniya of bromide reduces time of the beginning of its action and increases action duration (see the section "Pharmacodynamics").

Maintenance doses. The recommended maintenance dose makes 0,15 mg/kg a bromide rokuroniya; in case of a long inhalation anesthesia it is necessary to reduce it to 0,075-0,1 mg/kg. It is the best of all to enter maintenance doses while amplitude of muscular contractions is recovered to 25% of reference level or at emergence of 2-3 answers when monitoring in the mode of four-digit stimulation (TOF).

Continuous infusion. If a rokuroniya bromide is entered by means of continuous infusion, the bromide rokuroniya and when neuromuscular conductivity begins to be recovered, begin infusion is recommended to begin with a load dose 0,6 mg/kg. Speed of infusion should be picked up so that sokratitelny reaction of skeletal muscles was at the level of 10% of reference level or maintenance of 1-2 answers when monitoring in the mode of four-digit stimulation (TOF). Adults at intravenous general anesthesia have an infusion speed necessary for maintenance of the neuromuscular block at this level, makes 0,3-0,6 мг/кг×ч, and at an inhalation anesthesia - 0,3-0,4 мг/кг×ч. It is recommended to carry out continuous monitoring of neuromuscular conductivity as the necessary speed of infusion can vary depending on specific features of the patient and from various methods of anesthesia.

Children. For children since 1 month the recommended dose for an intubation when carrying out usual anesthesia (0.6 mg/kg a bromide rokuroniya) and a maintenance dose (0.15 mg/kg a bromide rokuroniya) same, as well as for adults.

When performing continuous infusion in pediatrics infusion speed same, as well as for adults (0,3-0,6 mg/kg/h), except for children (2-11 years) by whom higher speeds of infusion can be required. Initial speed of infusion for children is recommended same, as well as for adults (0,3-0,6 mg/kg/h). Already during the procedure speed has to be corrected to support amplitude of muscular contractions at the level of 10% of control amplitude or existence of 1-2 answers when monitoring in the mode of four-digit stimulation (TOF).

At the moment the bromide rokuroniya at newborns (0-1 month) is not enough data on use.

Experience of use a bromide rokuroniya during the procedure of bystry successive induction of anesthesia at children is limited. Therefore a rokuroniya bromide is not recommended for simplification of carrying out an intubation of a trachea during bystry successive induction of anesthesia at children.

Patients of advanced age and patients with diseases of a liver and/or bilious ways and/or a renal failure. The standard intubation dose for patients of advanced age and patients with diseases of a liver and/or biliary tract, and/or in the presence of a renal failure when carrying out usual anesthesia makes 0,6 mg/kg a bromide rokuroniya. When holding a procedure of bystry successive induction at patients with the estimated prolonged duration of action of a muscle relaxant the bromide rokuroniya is recommended to use a dose of 0.6 mg/kg.

Irrespective of technology of introduction, the recommended maintenance dose for these patients makes 0,075-0,1 mg/kg a bromide rokuroniya, the recommended infusion speed - 0,3-0,4 mg / to / h (see also "Continuous infusion").

Patients with the excess body weight and obesity. When using drug at patients with the excess body weight or obesity (those patients, which value of an index of body weight more than 30 are considered) doses a rokuroniya of bromide should be reduced, calculating them, proceeding from normal for this age and a floor of indicators of an index of body weight.

Use in intensive care unit. Trachea intubation. Doses are similar to that at surgical interventions.

Maintenance doses. The bromide rokuroniya, with the subsequent transfer into continuous infusion of drug at recovery of neuromuscular conductivity to 10% of initial level or obtaining 1-2 answers at stimulation in the TOF mode is recommended to begin with a dose 0,6 mg/kg. Doses a rokuroniya of bromide have to be picked up individually depending on effect. The recommended initial speed of infusion for maintenance of the neuromuscular block at the level of 80-90% (1-2 answers at stimulation in the TOF mode) at adult patients makes 0,3-0,6 mg / кгч within the first hour of introduction then, for 6-12 hours it is necessary to reduce infusion speed, according to individual reaction of the patient. After that the individual needs for a certain dose of drug remain rather constant.

In controlled clinical trials considerable interindividual variability concerning the hour speed of infusion, with average value of 0,2-0,5 mg / кгч depending on the reason and extent of organ disturbance(s), the accompanying drug treatment and individual characteristics of the patient was revealed. For ensuring optimum control over each patient it is strongly recommended to carry out continuous monitoring of neuromuscular conductivity. Administration of drug lasting up to 7 days is investigated.

Эсмерон® it is not recommended to apply to simplification of carrying out artificial ventilation of the lungs in intensive care unit at children and patients of advanced age due to the lack of data on safety and efficiency of drug at these groups of patients.

Features of use:

Use at pregnancy and feeding by a breast. Pregnancy. In the relation a rokuroniya of bromide there are no clinical data on effect of drug during pregnancy (except for Cesarean section). Purpose of the drug Esmeron® at pregnant women in connection with insufficiency of these clinical trials is not recommended (except for Cesarean section).

Cesarean section. When carrying out operation of Cesarean section, the drug Esmeron® can be used as a part of a technique of bystry successive induction of anesthesia if difficulties at an intubation of a trachea are not assumed and the sufficient dose of anesthetic, or after an intubation using succinylcholine is entered. It is shown that use of the drug Esmeron® in a dose of 0,6 mg/kg is safe at the women who are exposed to Cesarean section. The drug Esmeron® does not influence assessment on a scale Apgar, a muscle tone of a fruit or its cardiorespiratory adaptation. Analyses of blood samples from an umbilical cord demonstrate that only very insignificant quantities a rokuroniya of bromide get through a placental barrier that does not lead to emergence of clinically significant undesirable effects at the newborn.

Note 1: doses of 1,0 mg/kg were investigated when carrying out bystry successive induction of anesthesia, but not at the patients who are exposed to operation of Cesarean section. Therefore in this group of patients only the dose of 0,6 mg/kg is recommended.

Note 2: Recovery of neuromuscular conductivity after introduction of muscle relaxants can be slow or to be incomplete at the patients receiving magnesium salts for treatment of toxicosis of pregnant women as salts of magnesium strengthen the neuromuscular block. Therefore at such patients of a dose of the drug Esmeron® have to be reduced and they need to be titrated depending on the muscular answer.

Lactation. Now remains to unknown whether the drug Esmeron® at the person with breast milk is removed. Purpose of the drug Esmeron® in the period of a lactation in connection with insufficiency of these clinical trials is not recommended.

Use at abnormal liver functions. With care: liver failure.

Use at renal failures. With care: renal failure.

Use for children. It is contraindicated at children's age up to 1 month (in connection with insufficiency of data).

Эсмерон® it is not recommended to apply to simplification of carrying out artificial ventilation of the lungs in intensive care unit at children due to the lack of data on safety and efficiency of drug at these groups of patients.

Use for elderly patients. Эсмерон® it is not recommended to apply to simplification of carrying out artificial ventilation of the lungs in intensive care unit at patients of advanced age due to the lack of data on safety and efficiency of drug at these groups of patients.

Special instructions. As Esmeron ®не contains drug preservative, solution needs to be used right after opening of a bottle.

After cultivation by infusional liquids drug remains chemically and physically stable within 72 hours at a temperature of 30 °C. From the microbiological point of view divorced drug has to be used immediately. If drug is not used immediately, then the patient/doctor are responsible for time and storage conditions before use which usually should not exceed 24 hours at a temperature from 2 to 8 °C, except a case when cultivation is carried out in controlled and validirovanny aseptic conditions.

If Esmeron® is entered through uniform infusional system with other medicines, it is necessary to wash out carefully system (0,9% NaCl solution) between the administration of the drug Esmeron® and drugs having with it incompatibility and also if compatibility is not established.

As Esmeron® causes paralysis of respiratory muscles, the patients receiving this drug need absolutely to carry out artificial ventilation of the lungs up to adequate recovery of independent breath. As well as when using other muscle relaxants, it is important to provide possible difficulties of an intubation of a trachea, especially in case of use of drug as a part of a technique of bystry successive induction of anesthesia.

As well as at use of other muscle relaxants, cases of development of the residual block and after drug Esmeron® use were noted. To warn the complications resulting from development of the residual block it is recommended to carry out extubation of a trachea only after neuromuscular conductivity is recovered sufficiently. It is necessary to consider also other factors which can cause development of the residual block after extubation in the postoperative period (for example, medicinal interaction or a condition of the patient). It is necessary to consider the possibility of administration of the drugs recovering neuromuscular conductivity, especially in those cases at which emergence of the residual block is most probable.

After introduction of muscle relaxants anaphylactic reactions can develop. Therefore it is always necessary to undertake necessary precautionary measures which purpose is treatment of such reactions. Precautionary measures have to be taken especially in the presence of anaphylactic reactions to muscle relaxants in the anamnesis as cases of cross allergic reactivity on muscle relaxants are known.

After long introduction of muscle relaxants to the patients who are in intensive care unit development of the prolonged neuromuscular block and/or muscular weakness can be noted. It is necessary for prevention of possible prolongation of the neuromuscular block and/or overdose that during the entire period of use of muscle relaxants monitoring of neuromuscular conductivity, and also that patients received adequate anesthesia and sedative drugs was carried out. Moreover, muscle relaxants should be entered in carefully picked up doses according to individual reaction of the patient, and introduction has to be carried out by the experienced doctor familiar with action of muscle relaxants or under its observation, and also when using the corresponding technology of neuromuscular monitoring.

After long introduction of not depolarizing muscle relaxants to combinations with therapy by glucocorticosteroids in intensive care unit development of a myopathy is possible. Therefore the patient receiving both muscle relaxants, and glucocorticosteroids, the period of introduction of a muscle relaxant has to be whenever possible most limited. If succinylcholine is applied to an intubation, then administration of the drug Esmeron® should be postponed until clinical recovery of neuromuscular conductivity after the block called by succinylcholine.

The following factors can influence pharmacokinetics and/or a pharmacodynamics of the drug Esmeron®: diseases of a liver and/or biliary tract and renal failure. As the rokuroniya bromide is removed with urine and bile, it should be used with care at patients with clinically expressed diseases of a liver and/or biliary tract and/or a renal failure. At these groups of patients action prolongation a bromide rokuroniya was observed at doses of 0,6 mg/kg.

Increase in time of circulation. The states connected with increase in time of circulation of drug in blood, such as cardiovascular diseases, senile age and the puffiness leading to increase in volume of distribution can promote later beginning of effect of drug. Duration of action can be also increased because of reduced clearance of plasma.

Diseases of neuromuscular system. As well as other muscle relaxants, Esmeron® should be applied with extreme care at patients with diseases of neuromuscular system or the transferred poliomyelitis as reaction to muscular relaxants can be significantly changed in these cases. Expressiveness and the direction of these changes can be various. With a heavy myasthenia or a myasthenic syndrome (Eaton-Lambert's syndrome) small doses of the drug Esmeron® can call the expressed neuromuscular block therefore the dose of the drug Esmeron® should be selected according to individual reaction of the patient in patients.

Hypothermia. When carrying out surgical interventions against the background of a hypothermia the blocking effect of the drug Esmeron® on neuromuscular system amplifies, and duration of action increases.

Obesity. As well as increase in duration of action and time of spontaneous recovery of neuromuscular conductivity when using at the patients having obesity can be peculiar to other muscle relaxants, the drug Esmeron® (when the dose is calculated proceeding from the actual body weight).

Burns. At patients with burns resistance to not depolarizing to muscle relaxants can develop. It is necessary to carry out selection of an effective dose by a titration method.

States which can strengthen effect of the drug Esmeron®. Gipokalemiya (for example, after heavy vomiting, diarrhea or treatment by diuretics), a gipermagniyemiya, a hypocalcemia (after massive transfusions), a hypoproteinemia, dehydration, acidosis, a hypercapnia, a cachexia.

In this regard, heavy disturbances of balance of electrolytes, changes рН blood or dehydration have to be, whenever possible, corrected.

Influence on ability to drive the car and to work with mechanisms. As the drug Esmeron® is used as supportive application when carrying out the general anesthesia, it is necessary to observe the usual precautionary measures recommended after carrying out the general anesthesia for ambulatory patients. It is not recommended to manage potentially dangerous mechanisms or to drive the car within 24 hours after a complete recovery of the neuromuscular conductivity caused by the drug Esmeron®.

Side effects:

The most often arising side medicinal reactions include: pain in the place of an injection, change of the main indicators of a condition of an organism (tachycardia, hypotension) and increase in duration of the neuromuscular block. The most often reported serious side medicinal reactions during the post-registration period of observation of drug are anaphylactic and anaphylactoid reactions and the related symptoms. See also explanations in the table is lower.

Anaphylaxis. Very seldom, but after all it is reported about emergence of heavy anaphylactic reactions as a result of use of muscle relaxants, including ^Esmeron®. Anaphylactic/anaphylactoid reactions: a bronchospasm, changes from cardiovascular system (for example, hypotension, tachycardia, a vascular collapse shock) and changes from skin (for example, a Quincke's disease, a small tortoiseshell). In certain cases these reactions were fatal. Because of possible weight of these reactions it is always necessary to mean a possibility of their emergence and to observe the appropriate measures of precaution.

As it is known that muscle relaxants are capable to cause release of a histamine both locally in the place of an injection, and it is system, therefore at administration of these drugs it is always necessary to consider possible developing of an itch and эритематозньгх reactions in the place of an injection and/or generalized histamine-like (anaphylactoid) reactions (see also anaphylactic reactions above).

Only insignificant increase in average concentration of a histamine in plasma after bystry bolyusny introduction of 0,3-0,9 mg/kg a bromide rokuroniya was shown.

Prolongation of the neuromuscular block. The most frequent side reaction of muscle relaxants as class of medicines, lengthening of the period of their pharmacological action over a necessary span is. Extent of this reaction can vary from skeletal and muscular weakness to the deep and long paralysis of skeletal muscles leading to respiratory
insufficiency or apnoea.

Myopathy. The myopathy was noted after use of various muscle relaxants in intensive care unit in a combination with glucocorticosteroids (see the section "Special Instructions").

Local reactions in the place of an injection. During bystry successive induction of anesthesia it was reported about painful feelings at an injection, in particular, when the patient still is in consciousness, and in particular at use of a propofol as means for anesthesia induction. In clinical trials pain at an injection was noted at 16% of the patients who were exposed to bystry successive induction of anesthesia using a propofol, and less than at 0,5% of the patients who were exposed to bystry successive induction of anesthesia using fentanyl and thiopental of sodium.

Interaction with other medicines:

It is shown that below the listed medicines influence force and/or duration of action of not depolarizing muscle relaxants.

Influence of other medicines on Esmeron®. Strengthening of effect. Galogenezirovanny flying anesthetics strengthen the neuromuscular block called by the drug Esmeron®. This effect becomes noticeable only at introduction of maintenance doses (see. "Route of administration and doses"). Recovery of neuromuscular conductivity by means of inhibitors of acetylcholinesterase can be slowed down.

The previous administration of succinylcholine (see. "Special instructions").

The long accompanying introduction of glucocorticosteroids and the drug Esmeron® in intensive care unit can lead to increase in duration of the neuromuscular block or to a myopathy (see. "Special instructions" and "Side effect").

Drugs of other groups: antibiotics (aminoglycosides, linkozamida and polypeptide antibiotics, antibiotics of an atsilamino-penicillinic row); diuretics, quinidine and its isomer quinine, magnesium salts, blockers of slow calcium channels, lithium salts, local anesthetics (lidocaine intravenously, bupivacaine epiduralno) and acute introduction of Phenytoinum or beta adrenoblockers.

Rekurarization was marked out after postoperative introduction: aminoglycoside, a linkozamid, polypeptide and acylaminopenicillinic antibiotics, quinidine, quinine and salts of magnesium (see. "Special instructions").

Decrease in effect:

— The previous long introduction of Phenytoinum or carbamazepine;

— Inhibitors of proteases (габексат, улинастатин).

Change of effect. Introduction of other not depolarizing muscle relaxants to combinations with the drug Esmeron® can cause easing or strengthening of the neuromuscular block, depending on priority of introduction and from the applied muscle relaxant.

Succinylcholine which is entered after the drug Esmeron® can strengthen or weaken the neuromuscular block called by the drug Esmeron®.

Influence of the drug Esmeron® on other medicines. The drug Esmeron® combination with lidocaine can lead to more quick start of effect of lidocaine.

Pharmaceutical interaction. Incompatibility. It is established that the drug Esmeron® is incompatible for introduction in one syringe with the solutions containing the following drugs: Amphotericinum In, amoxicillin, Azathioprinum, cefazolin, клоксациллин, dexamethasone, diazepam, эноксимон, erythromycin, famotidine, furosemide, a sodium hydrocortisone succinate, insulin, metogeksitat, Methylprednisolonum, sodium Prednisolonum succinate, sodium thiopental, Trimethoprimum and Vancomycinum. Эсмерон® Intralipid is incompatible also with drug (fatty emulsions for parenteral administration).

The drug Esmeron® cannot be mixed with other medicines, except for those which are provided below.

Compatibility when mixing with other medicines. It is shown that in nominal concentration of 0,5 mg/ml and 2,0 mg/ml the drug Esmeron® is compatible from 0,9% of sodium chloride, 5% a dextrose, 5% a dextrose in 0,9% chloride sodium solution, sterile water for injections, Ringer's solution and drug Gemazzel (полигелин). Introduction has to be begun at once after mixing and is finished within 24 hours. Unused solutions should be poured out.

Contraindications:

— hypersensitivity to a rokuroniya either to bromide ion or to any excipient;

— children's age up to 1 month (in connection with insufficiency of data);

— pregnancy, except for Cesarean section (in connection with insufficiency of data);

— the lactation period (in connection with insufficiency of data).

With care: the liver and/or renal failure, cardiovascular diseases which are followed by the expressed circulatory unefficiency (heart diseases, pulmonary hypertensia), diseases of neuromuscular system (including a myasthenia), obesity, disturbance of acid-base balance, burns, a cachexia, advanced age, muscle relaxation at Cesarean section. When carrying out operation of Cesarean section the recommended dose a rokuroniya of bromide of 0,6 mg/kg of body weight as use of higher doses (1,0 mg/kg of body weight) was not investigated.

Overdose:

In case of overdose and development of the prolonged neuromuscular block the patient needs to continue auxiliary artificial ventilation of the lungs and administration of ssdativny drugs. When spontaneous recovery of neuromuscular conductivity begins, it is necessary to enter the corresponding dose of inhibitor of acetylcholinesterase (for example, a neostigmina of methylsulphonate, an edrofoniya of chloride, bromide pyridostigmine). If administration of inhibitor of acetylcholinesterase does not remove the blocking effect of the drug Esmeron®, it is necessary to continue ventilation until independent breath is recovered. Repeated administration of inhibitor of acetylcholinesterase can be dangerous.

Storage conditions:

List A. to store at a temperature of 2-8 °C. To store in the place, unavailable to children. A period of validity - 3 years.

Issue conditions:

According to the recipe

Packaging:

2.5 ml - bottles (10) - packs cardboard.