What is the recommended dose of Rocuronium (rocuronium bromide) for intubation in children?

Recommended Rocuronium Dosage for Intubation in Children

For pediatric intubation, the recommended dose of rocuronium is 0.6 mg/kg as the standard intubation dose, with a higher dose of 0.9-1.2 mg/kg recommended for rapid sequence intubation when used as an alternative to succinylcholine. 1, 2

Standard Intubation Dosing

• The FDA-approved initial intubation dose of rocuronium in pediatric patients is 0.6 mg/kg, though a lower dose of 0.45 mg/kg may be used depending on anesthetic technique and patient age 1
• For sevoflurane induction, rocuronium doses of 0.45-0.6 mg/kg generally produce excellent to good intubating conditions within 75 seconds 1
• When halothane is used, a 0.6 mg/kg dose results in excellent to good intubating conditions within 60 seconds 1
• The time to maximum block for an intubating dose is shortest in infants (28 days to 3 months) and longest in neonates (birth to less than 28 days) 1

Rapid Sequence Intubation Dosing

• For rapid sequence intubation in children, a dose of at least 0.9 mg/kg rocuronium is recommended to achieve comparable intubation conditions to succinylcholine 2, 3
• The French guidelines recommend rocuronium at a dose >0.9 mg/kg as a good alternative to succinylcholine when succinylcholine is contraindicated 3
• The American Academy of Pediatrics recommends rocuronium at >0.9 mg/kg when used as an alternative to succinylcholine in rapid sequence induction 2

Age-Specific Considerations

• The duration of clinical relaxation following an intubating dose is shortest in children (>2 years to 11 years) and longest in infants 1
• When sevoflurane is used for induction and isoflurane/nitrous oxide for maintenance, maintenance dosing can be administered as bolus doses of 0.15 mg/kg at reappearance of T3 in all pediatric age groups 1
• Maintenance dosing can also be administered at the reappearance of T2 at a rate of 7-10 mcg/kg/min, with the lowest dose requirement for neonates and the highest for children (>2 years to 11 years) 1

Rocuronium vs. Succinylcholine

• Succinylcholine remains the first choice for rapid sequence induction in children when not contraindicated 3
• Age-appropriate doses of succinylcholine are: <1 month: 1.8 mg/kg, 1 month to 1 year: 2.0 mg/kg, 1-10 years: 1.2 mg/kg, >10 years: 1.0 mg/kg 4, 3
• Rocuronium should be used when succinylcholine is contraindicated, such as in cases of primary muscle damage (myopathies) or up-regulation of nicotinic acetylcholine receptors 3, 4
• The main disadvantage of rocuronium compared to succinylcholine is its longer duration of action 4

Practical Considerations

• Neuromuscular blockade monitoring is recommended following muscle relaxant use in all pediatric patients, with an estimated 28% frequency of residual neuromuscular blockade 3
• Always flush IV tubing with saline before administering rocuronium after other medications to avoid precipitation and obstruction 2
• Personnel with skills in airway management must be present and prepared to respond when rocuronium is administered 2
• Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available 2
• Rocuronium does not provide sedation, analgesia, or amnesia, so appropriate sedative/analgesic agents must be administered concurrently 2

Special Situations

• Intramuscular administration of rocuronium is not recommended for rapid sequence intubation in pediatric patients as it does not consistently provide satisfactory tracheal intubating conditions 5
• For inhalation induction with sevoflurane, a lower rocuronium dose of 0.29 mg/kg may be sufficient to optimize intubation conditions for surgery of short duration 6
• In patients receiving other sedatives or narcotics, lower doses of rocuronium may be sufficient 2