What is the recommended dosage of ketamine and rocuronium for Rapid Sequence Intubation (RSI)?

Recommended Dosage for Ketamine and Rocuronium in Rapid Sequence Intubation

For rapid sequence intubation (RSI), the recommended dosage is ketamine 1-2 mg/kg IV for induction and rocuronium 1.0-1.2 mg/kg IV for neuromuscular blockade. 1

Ketamine Dosing

• Ketamine should be dosed at 1-2 mg/kg IV for RSI in critically ill adult patients 1, 2
• In hemodynamically unstable patients, ketamine is preferred due to its sympathomimetic properties that help maintain cardiovascular stability 2
• Higher doses of ketamine (>2 mg/kg) are associated with increased risk of adverse events including hypotension, laryngospasm, and bradycardia, and should be avoided 3
• For patients with cardiovascular compromise, consider using the lower end of the dosing range (1 mg/kg) to minimize hemodynamic effects while still achieving adequate sedation 1

Rocuronium Dosing

• Rocuronium should be administered at 1.0-1.2 mg/kg IV for RSI to ensure optimal intubating conditions 1, 2
• The FDA-approved dosing for rocuronium in RSI is 0.6-1.2 mg/kg, but higher doses within this range (≥1.0 mg/kg) are recommended for emergency airway management 4
• Higher doses of rocuronium (≥1.4 mg/kg) have been associated with improved first-attempt success rates when using direct laryngoscopy, without increasing adverse events 5
• Rocuronium should be given as early as practical after induction to minimize apnea time and risk of patient coughing 1

Timing Considerations

• After administering ketamine and rocuronium, ensure full neuromuscular blockade before attempting intubation 1
• Wait at least 60 seconds after rocuronium administration before attempting intubation, or use a peripheral nerve stimulator to confirm adequate blockade 1, 4
• Maximum blockade with rocuronium is typically achieved within 3 minutes of administration 4

Special Considerations

• In patients at risk for cardiovascular instability, ketamine may be preferred over other induction agents due to its relative hemodynamic stability 1, 2
• For patients with pre-intubation hypotension, higher doses of rocuronium (≥1.4 mg/kg) have been associated with higher first-attempt success without increasing adverse events 5
• When using high-dose rocuronium, consider having sugammadex available for reversal if needed in a "can't intubate, can't ventilate" scenario 1
• Ensure vasopressors are immediately available for managing potential hypotension during RSI 1

Pitfalls and Caveats

• Avoid excessive ketamine dosing (>2 mg/kg), as this has been associated with increased odds of adverse events including hypotension, laryngospasm, and bradycardia 3
• In critically ill patients with depleted catecholamine stores, ketamine may paradoxically cause hypotension despite its sympathomimetic properties 1
• Ensure full neuromuscular blockade before attempting intubation to prevent coughing or movement that could increase the risk of aspiration 1
• The combination of ketamine with rocuronium has been shown to provide excellent intubating conditions in emergency settings with less need for medication redosing compared to other regimens 6