What is the recommended dose of rocuronium (neuromuscular blocker) for intubation?

Rocuronium Dosing for Intubation

For rapid sequence intubation in adults, administer rocuronium 0.6-1.2 mg/kg, with doses ≥0.9 mg/kg recommended when rapid onset comparable to succinylcholine is required. 1

Standard Intubation Dosing

The FDA-approved initial dose is 0.6 mg/kg for routine tracheal intubation, which provides:

• Neuromuscular block sufficient for intubation (≥80% block) in a median of 1 minute 1
• Most patients intubated within 2 minutes 1
• Maximum blockade achieved in <3 minutes 1
• Clinical relaxation duration of 31 minutes (range 15-85 minutes) under opioid/nitrous oxide/oxygen anesthesia 1

A lower dose of 0.45 mg/kg may be used for elective procedures when slower onset is acceptable, providing intubation conditions in a median of 1.3 minutes and 22 minutes of clinical relaxation. 1 However, approximately 16% of patients receiving this lower dose achieve <90% block and may have more rapid recovery (12-15 minutes). 1

Rapid Sequence Intubation

For rapid sequence intubation, rocuronium 0.6-1.2 mg/kg provides excellent or good intubating conditions in most patients in <2 minutes. 1 The European Society of Anaesthesiology and American Academy of Pediatrics recommend doses ≥0.9 mg/kg when rocuronium is used as an alternative to succinylcholine to achieve comparable intubation conditions. 2, 3

Evidence Supporting Higher Doses in RSI:

Recent emergency department data demonstrates that rocuronium ≥1.4 mg/kg is associated with significantly higher first-attempt success when using direct laryngoscopy (adjusted OR 1.9,95% CI 1.3-2.7) compared to standard 1.0-1.1 mg/kg dosing, with no increase in adverse events. 4 This is particularly relevant for patients with pre-intubation hypotension (SBP <100 mmHg), where higher doses achieved 94.9% versus 88.6% first-attempt success. 4

Large bolus doses of 0.9 or 1.2 mg/kg can be administered safely under opioid/nitrous oxide/oxygen anesthesia without adverse cardiovascular effects. 1

Dosing Algorithm

Choose your rocuronium dose based on clinical urgency:

• Elective intubation, no aspiration risk: 0.45-0.6 mg/kg 1
• Standard rapid sequence intubation: 0.6-0.9 mg/kg 1
• RSI requiring succinylcholine-equivalent conditions: ≥0.9 mg/kg 2, 3
• Difficult airway anticipated with direct laryngoscopy: Consider ≥1.4 mg/kg 4

Maintenance Dosing

After initial intubation, maintenance doses of 0.1-0.2 mg/kg should be administered at 25% recovery of control T1 (3 twitches of train-of-four), providing 12-24 minutes of additional clinical duration. 1 Dosing must be guided by neuromuscular monitoring and not administered until recovery of neuromuscular function is evident. 1

Continuous infusion may be initiated at 10-12 mcg/kg/min only after early evidence of spontaneous recovery, with rates adjusted to 4-16 mcg/kg/min based on peripheral nerve stimulator monitoring. 1

Critical Safety Considerations

Rocuronium does not provide sedation, analgesia, or amnesia—appropriate sedative/analgesic agents must be administered concurrently. 2 Personnel skilled in airway management must be present with age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation immediately available. 2

Always flush IV tubing with saline before administering rocuronium after other medications to avoid precipitation and IV obstruction. 2

Use a peripheral nerve stimulator to monitor drug effect, need for additional doses, adequacy of recovery, and to decrease complications of overdosage. 1

Special Populations

In renal or hepatic failure, do not modify the initial dose regardless of muscle relaxant type, as the time to onset remains unchanged despite extended duration of action. 5 The usual intubation dose ensures effective concentrations during intubation. 5

In elderly patients and those with severe renal failure (creatinine clearance <30 mL/min), sugammadex efficacy for reversal may be decreased, particularly with deep blockade. 5

Inhalation anesthetics (particularly enflurane and isoflurane) enhance neuromuscular blocking action—expect extended clinical relaxation duration and consider dose adjustments for maintenance. 1