What is the recommended use and dosage of Rocuronium (rocuronium) for facilitating tracheal intubation and skeletal muscle relaxation during surgery or mechanical ventilation?

Rocuronium for Tracheal Intubation and Skeletal Muscle Relaxation

Rocuronium is strongly recommended for facilitating tracheal intubation at a dose of 0.6 mg/kg, which provides excellent-to-good intubating conditions in most patients within 2 minutes and reduces pharyngeal/laryngeal injury compared to intubation without muscle relaxants. 1, 2

Primary Indications and Dosing

Standard Tracheal Intubation

• Administer rocuronium 0.6 mg/kg IV for routine intubation, which achieves 80% or greater neuromuscular block in a median time of 1 minute, with most intubations completed within 2 minutes 2
• This dose provides 31 minutes (range 15-85 minutes) of clinical relaxation under opioid/nitrous oxide/oxygen anesthesia 2
• Maximum blockade occurs in less than 3 minutes in most patients 2

Alternative Lower Dose Option

• Rocuronium 0.45 mg/kg may be used when shorter duration is desired, achieving intubation conditions in a median of 1.3 minutes and providing 22 minutes (12-31 minutes) of clinical relaxation 2
• However, approximately 16% of patients receiving 0.45 mg/kg achieve less than 90% block and may have more rapid recovery (12-15 minutes) 2

Rapid Sequence Intubation

• For rapid sequence intubation, use rocuronium 0.6-1.2 mg/kg, which provides excellent or good intubating conditions in most patients in less than 2 minutes 2
• Rocuronium at doses greater than 0.9 mg/kg shows no inferiority to succinylcholine 1.0 mg/kg for intubation conditions, though succinylcholine still provides slightly better conditions overall (RR = 0.86; 95% CI: 0.81-0.92) 1
• The modified timing principle (administering rocuronium before propofol) can reduce apnea time to approximately 38.5 seconds compared to 100.7 seconds with conventional succinylcholine technique 3

Critical Clinical Benefits

Reduction in Airway Injury

• Using muscle relaxants reduces pharyngeal and/or laryngeal injuries from 22.6% to 9.7% (GRADE 1+ recommendation) 1
• This reduction was consistently demonstrated across six randomized controlled studies involving 746 patients 1
• The quality of intubation directly correlates with postoperative complications including vocal cord damage and hoarseness 1

Improved Intubation Conditions

• Muscle relaxants reduce poor intubating conditions from 24.6% to 4.1% in controlled trials 1
• In a large cohort of 103,784 patients, poor intubating conditions occurred in 6.7% without muscle relaxants versus 4.5% with muscle relaxants 1
• Muscle relaxant-free intubation is an independent risk factor for difficult intubation 1

Maintenance Dosing During Surgery

Bolus Maintenance

• Administer maintenance doses of 0.1-0.2 mg/kg at 25% recovery of control T1 (defined as 3 twitches on train-of-four monitoring) 2
• Maintenance doses provide the following clinical durations under opioid/nitrous oxide/oxygen anesthesia: 2
  • 0.1 mg/kg: 12 minutes (range 2-31 minutes)
  • 0.15 mg/kg: 17 minutes (range 6-50 minutes)
  • 0.2 mg/kg: 24 minutes (range 7-69 minutes)

Continuous Infusion

• Initiate infusion at 10-12 mcg/kg/min only after early evidence of spontaneous recovery from the intubating dose 2
• Adjust infusion rates from 4-16 mcg/kg/min based on peripheral nerve stimulator monitoring 2
• Starting infusion after substantial return of neuromuscular function (>10% of control T1) may require additional bolus doses 2

Specific Clinical Scenarios

Abdominal Surgery

• Rocuronium is strongly recommended for abdominal laparotomy or laparoscopy (GRADE 1+ recommendation) to improve surgical field quality 1
• Intraoperative neuromuscular blockade significantly improves surgical conditions in laparoscopic cholecystectomies, hysterectomies, and laparotomy procedures 1

Laryngospasm Management

• For laryngospasm, rocuronium 0.1-0.2 mg/kg is effective when adequate depth of anesthesia is achieved, though succinylcholine remains the gold standard 1
• Low concentrations of rocuronium are sufficient to relax laryngeal muscles if anesthesia depth is adequate 1

Supraglottic Device Insertion

• Routine use of rocuronium for supraglottic device insertion is NOT recommended (GRADE 2 recommendation) 1
• Success rates for laryngeal mask insertion are commonly high without muscle relaxants when adequate propofol is used 1
• Neuromuscular blockade may be useful when hypnotic/opioid doses are low or when non-propofol induction agents are used 1

Special Populations

Obese Patients

• Dose rocuronium based on actual body weight, not ideal body weight 2
• Dosing based on ideal body weight results in longer time to maximum block, shorter clinical duration (25 minutes vs. 31 minutes), and inferior intubating conditions 2

Geriatric Patients (≥65 years)

• Use standard dose of 0.6 mg/kg in geriatric patients 2
• Intubating conditions are achieved in a median of 2.3 minutes (range 1-8 minutes) 2
• Recovery times from 25% to 75% are not prolonged compared to younger adults 2

Obstetric Patients

• Rocuronium is NOT recommended for rapid sequence induction in Cesarean section 2
• When rocuronium 0.6 mg/kg was used with thiopental 3-4 mg/kg, 5 of 13 women had poor or inadequate intubating conditions at 60 seconds 2
• Umbilical venous plasma concentrations reach 18% of maternal concentrations at delivery 2

Monitoring Requirements

Neuromuscular Monitoring

• Intraoperative monitoring of neuromuscular blockade is strongly recommended (GRADE 1+ recommendation) 1
• Use peripheral nerve stimulator to monitor drug effect, need for additional doses, and adequacy of recovery 2
• If instrumental monitoring is used, the corrugator supercilii muscle is the preferred site due to its sensitivity and kinetics comparable to laryngeal muscles 1

Critical Safety Considerations

Medication Error Prevention

• Store rocuronium with cap and ferrule intact to minimize risk of selecting the wrong product, as accidental administration of neuromuscular blocking agents may be fatal 2

Contraindications in Specific Settings

• Do NOT use rocuronium routinely for agitation management in intubated ICU patients; optimize sedation and analgesia first, reserving neuromuscular blocking agents only for life-threatening situations when deep sedation fails 4
• Long-term NMBA use (>12 hours) is associated with prolonged paralysis, skeletal muscle weakness, pneumonia, and worse neurological outcomes 4

Potentiation by Inhalational Agents

• Expect prolonged clinical relaxation under halothane, isoflurane, and enflurane anesthesia compared to opioid/nitrous oxide/oxygen technique 1, 2
• Inhalation anesthetics enhance neuromuscular blocking action; adjust infusion rates from 4-16 mcg/kg/min accordingly 2

Reversal Considerations

• Rocuronium with sugammadex reversal provides faster and more reliable recovery (mean 4.7 minutes) than succinylcholine alone 1
• Ensure immediate availability of appropriate sugammadex doses for emergency reversal 1