From the Guidelines
Rocuronium and Ketamine dosing for RSI should be 1.0-1.2 mg/kg and 1-2 mg/kg, respectively.
Rationale
- The choice of Rocuronium as a neuromuscular blocking agent (NMBA) is suggested when there are no known contraindications to succinylcholine, with a dose of 1.0-1.2 mg/kg 1.
- Ketamine is a reasonable option for RSI due to its quick onset and short duration of action, with a suggested dose of 1-2 mg/kg 1.
- The use of Ketamine as an induction agent has been compared to etomidate, with no difference in mortality or incidence of hypotension or vasopressor use in the peri-intubation period and through hospital discharge 1.
- The selection of a sedative-hypnotic agent, such as Ketamine, that attenuates hypotension during RSI is desirable, especially in critically ill patients 1.
- Rocuronium has a faster onset time compared to other non-depolarizing muscle relaxants, making it a suitable alternative to succinylcholine for RSI 1.
- The dose of Rocuronium should be above 0.9 mg/kg to facilitate tracheal intubation in patients with signs of distress 1.
- It is essential to note that the evidence is based on studies with varying levels of quality, and the recommendations are conditional, with a low to moderate quality of evidence 1.
From the Research
Rocuronium Dosing for Rapid Sequence Intubation (RSI)
- The recommended dose of rocuronium for RSI is typically 1.0 mg/kg, but the optimal dose is not clear 2.
- A study found that rocuronium doses ≥1.4 mg/kg were associated with higher first-attempt success when using direct laryngoscopy, with no increase in adverse events 2.
- Another study suggested that using corrected body weight (CBW) to calculate the rocuronium dose may provide similar intubation conditions as using actual body weight (ABW), with a shorter duration of action 3.
Ketamine Dosing for RSI
- Ketamine is typically dosed at 1 to 2 mg/kg intravenously for RSI, but some studies have used higher doses 4.
- A study found that high-dose ketamine (> 2 mg/kg) was associated with increased odds of adverse events, including hypotension, laryngospasm, and oxygen desaturation 4.
- Another study used a dose of 0.5 mg/kg ketamine in combination with etomidate and rocuronium for modified rapid-sequence induction, and found that it produced excellent intubating conditions in most patients 5.
Combination of Rocuronium and Ketamine for RSI
- A study found that the combination of etomidate, s-ketamine, and rocuronium produced excellent intubating conditions in most patients, with a dose of 0.6 mg/kg rocuronium and 0.5 mg/kg s-ketamine 5.
- Another study found that magnesium sulphate pretreatment was associated with excellent intubating conditions, but also with a burning or heat sensation in some patients 6.