Rocuronium Dose for Pediatric Rapid Sequence Intubation
For pediatric rapid sequence intubation, rocuronium should be dosed at greater than 0.9 mg/kg (typically 1.0-1.2 mg/kg) when used as an alternative to succinylcholine. 1, 2, 3
First-Line Agent Remains Succinylcholine
- Succinylcholine remains the preferred first-line muscle relaxant for pediatric RSI when not contraindicated, with age-specific dosing: <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 1, 2, 3
- Rocuronium is specifically recommended when succinylcholine is contraindicated, such as in cases of primary muscle damage (myopathies), neuromuscular diseases, or up-regulation of nicotinic acetylcholine receptors 1, 3
Rocuronium Dosing Specifics for RSI
- The minimum effective dose is >0.9 mg/kg, with doses of 1.0-1.2 mg/kg commonly used to achieve intubation conditions comparable to succinylcholine within 60 seconds 1, 2, 4, 3
- The FDA label states that rocuronium is NOT recommended for rapid sequence intubation in pediatric patients, listing only 0.6 mg/kg (or 0.45 mg/kg) for routine intubation 5
- However, multiple international guidelines supersede this FDA recommendation, consistently supporting doses >0.9 mg/kg for RSI specifically 1, 2, 4, 3
Critical Timing and Practical Considerations
- Intubation should be attempted at 60 seconds after rocuronium administration when using doses ≥1.0 mg/kg 6, 7
- The time between loss of consciousness and airway protection must be minimized, as younger children have shorter apnea tolerance before hypoxemia develops 1
- A major caveat: rocuronium at these doses produces significantly longer paralysis (70-90+ minutes) compared to succinylcholine (5 minutes), which limits its utility when rapid return of spontaneous ventilation is desired 8, 6
Essential Safety Requirements
- Personnel skilled in airway management must be immediately present and prepared to manage a failed airway 4, 3
- Age-appropriate equipment for suctioning, oxygenation, bag-mask ventilation, and surgical airway must be immediately available 4, 3
- Neuromuscular blockade monitoring is warranted, as residual blockade occurs in 28% of pediatric patients receiving muscle relaxants 1, 2, 3
- Rocuronium provides no sedation, analgesia, or amnesia—appropriate sedative/analgesic agents must be administered concurrently 4, 3
Dosing Based on Body Weight
- In obese pediatric patients, dose rocuronium based on actual body weight, not ideal body weight 5
- Always flush IV tubing with saline before administering rocuronium after other medications to prevent precipitation and IV obstruction 4, 3
Reversal Considerations
- Sugammadex availability for reversal should be confirmed before using rocuronium for RSI, though it may not be approved for all pediatric age groups in all regions 1, 2, 3
- The choice between succinylcholine and rocuronium should factor in the desired duration of paralysis, risk of difficult intubation, and presence of neuromuscular disease 1, 2