What are the recommended doses of paralytic (e.g. rocuronium) and sedative (e.g. propofol) for intubation?

Recommended Doses for Intubation

For rapid sequence intubation, use rocuronium 0.9-1.2 mg/kg (or succinylcholine 1.0 mg/kg in adults) combined with propofol 2 mg/kg and remifentanil 2 μg/kg for optimal intubation conditions. 1, 2, 3, 4

Paralytic Agent Dosing

Rocuronium (Preferred in Most Settings)

Standard Rapid Sequence Intubation:

• Dose: 0.9-1.2 mg/kg IV for excellent intubation conditions within 60 seconds 1, 2, 4
• Lower doses (0.6 mg/kg) provide adequate conditions but with slower onset (median 1 minute vs. immediate with higher doses) 4
• The 0.6 mg/kg dose is acceptable for non-emergent intubations where 2-3 minutes to optimal conditions is acceptable 4

Pediatric Dosing:

• Rapid sequence intubation: >0.9 mg/kg (same as adults when succinylcholine is contraindicated) 1, 2
• Routine paralysis: 0.1 mg/kg 1
• Standard intubation: 0.2 mg/kg 1

Key Advantage: Rocuronium at 1.2 mg/kg provides comparable first-pass success rates to succinylcholine with minimal cardiovascular effects, though duration is longer (30-60 minutes vs. 4-6 minutes) 3, 4

Succinylcholine (Alternative When Not Contraindicated)

Adult Dosing:

• Standard dose: 1.0 mg/kg IV for rapid sequence intubation 3
• Provides fastest onset and shortest duration of all paralytics 3

Pediatric Dosing (Age-Specific):

• <1 month: 1.8 mg/kg 2, 3
• 1 month to 1 year: 2.0 mg/kg 2, 3
• 1-10 years: 1.2 mg/kg 2, 3
• >10 years: 1.0 mg/kg 2, 3

Absolute Contraindications:

• History of malignant hyperthermia 3
• Primary muscle damage (myopathies, Duchenne muscular dystrophy) 5, 3
• Immobilization >3 days, burns, crush injuries, spinal cord injuries (risk of fatal hyperkalemia) 3
• Up-regulation of nicotinic acetylcholine receptors from chronic motor deficit 5

Sedative Agent Dosing

Propofol (Primary Induction Agent)

Standard Dose: 2 mg/kg IV for induction 6

• When combined with remifentanil 2 μg/kg and rocuronium 0.9-1.2 mg/kg, provides superior intubation conditions compared to thiopental-based regimens 7
• The propofol-rocuronium combination is significantly more effective than thiopental-rocuronium for rapid sequence intubation 7

Remifentanil (Adjunct Opioid)

Standard Dose: 2 μg/kg IV given 15 seconds before intubation attempt 6, 8

• Improves intubation conditions when combined with propofol and rocuronium 6
• Allows for lower doses of paralytic while maintaining acceptable conditions 6

Critical Timing Considerations

True Rapid Sequence Intubation Protocol:

1. Administer propofol 2 mg/kg IV 6
2. Immediately follow with rocuronium 0.9-1.2 mg/kg (or succinylcholine 1.0 mg/kg) 1, 4
3. Give remifentanil 2 μg/kg 15 seconds before intubation attempt 6
4. Attempt intubation at 60 seconds after rocuronium administration 4, 7

Important: The intubation model matters significantly—true RSI (immediate administration of paralytic after hypnotic with intubation within 60 seconds) requires higher rocuronium doses (0.9-1.2 mg/kg) for success comparable to succinylcholine 7

Special Population Adjustments

Renal or Hepatic Failure

• Do NOT modify the initial dose of rocuronium—time to onset remains unchanged despite prolonged duration of action 5, 1
• Consider using atracurium or cisatracurium for maintenance dosing due to organ-independent elimination 5

Cardiovascular Instability

• Rocuronium 0.6 mg/kg has minimal cardiovascular effects and can be used safely 1
• Large bolus doses (0.9-1.2 mg/kg) can be administered without adverse cardiovascular effects 4

Pediatric Considerations

• Always have atropine available for children aged 28 days to 8 years, particularly with succinylcholine use (prevents bradycardia) 3
• Neuromuscular monitoring is essential—28% of pediatric patients develop residual blockade 2
• Flush IV tubing with saline before administering rocuronium after other medications to prevent precipitation 1, 2

Common Pitfalls to Avoid

Inadequate Dosing:

• Using rocuronium 0.6 mg/kg for true RSI with thiopental induction results in poor conditions in 31% of patients 7
• The ED50 of rocuronium with propofol-remifentanil is only 0.20 mg/kg, but clinical dosing should be 0.8 mg/kg minimum for reliable conditions 6

Timing Errors:

• Attempting intubation before 60 seconds with standard rocuronium doses leads to suboptimal conditions 4, 7
• Modified RSI (delayed administration) requires different dosing considerations than true RSI 7

Reversal Preparedness:

• Sugammadex must be immediately available when using rocuronium, especially in pediatrics, to allow reversal if needed 2, 3
• Dantrolene must be available wherever succinylcholine is used (malignant hyperthermia risk) 3

Lack of Monitoring:

• Personnel skilled in airway management must be present 1, 2
• Age-appropriate equipment for suctioning, oxygenation, and ventilation must be immediately available 1, 2
• Remember: Rocuronium provides NO sedation, analgesia, or amnesia—concurrent sedative/analgesic agents are mandatory 1, 2