What is the protocol for using rocuronium (neuromuscular blocking agent) for Rapid Sequence Intubation (RSI)?

Rocuronium Protocol for Rapid Sequence Intubation

For RSI in critically ill adults, administer rocuronium at 1.0-1.2 mg/kg IV immediately after a sedative-hypnotic induction agent (ketamine 1-2 mg/kg or etomidate 0.3 mg/kg), and attempt intubation at 60 seconds after rocuronium administration. 1, 2

Dosing Protocol

Standard RSI Dose

• Rocuronium 0.6-1.2 mg/kg IV provides excellent or good intubating conditions in most patients within 60 seconds 2
• The optimal dose is 1.0-1.2 mg/kg for RSI to ensure rapid onset and optimal intubating conditions 1, 2
• The standard 0.6 mg/kg dose achieves intubation conditions in a median of 1 minute, but higher doses (0.9-1.2 mg/kg) provide more reliable conditions 2

Timing Sequence

• Administer the sedative-hypnotic induction agent first to prevent awareness during paralysis 1
• Give rocuronium immediately after confirming loss of consciousness 1
• Wait 60 seconds after rocuronium administration before attempting intubation 1, 2
• This 60-second interval is critical—attempting intubation earlier may result in suboptimal conditions 2

Induction Agent Selection

First-Line Options

• Ketamine 1-2 mg/kg IV is preferred in hemodynamically unstable patients due to sympathomimetic properties that maintain blood pressure 1
• Etomidate 0.3 mg/kg IV is an alternative with favorable hemodynamic profile, though it causes transient adrenal suppression 1
• The Society of Critical Care Medicine found no mortality difference between etomidate and other induction agents 3, 1

Critical Sequencing Rule

• Never administer rocuronium before the induction agent—this causes awareness during paralysis, which occurs in 2.6% of emergency department intubations when this error is made 4

Patient Positioning and Preoxygenation

Positioning

• Place patient in semi-Fowler position (head and trunk inclined) to improve first-pass success and reduce aspiration risk 3, 1
• This positioning increases functional residual capacity and improves preoxygenation 3

Preoxygenation Strategy

• Use high-flow nasal oxygen (HFNO) when challenging laryngoscopy is anticipated 1
• Use noninvasive positive pressure ventilation (NIPPV) in patients with severe hypoxemia (PaO2/FiO2 < 150) 1
• Preoxygenate for at least 2 minutes before induction 5

Comparison with Succinylcholine

When to Choose Rocuronium Over Succinylcholine

• Rocuronium is the alternative when succinylcholine is contraindicated 3, 1
• Absolute contraindications to succinylcholine include: malignant hyperthermia history, immobilization >3 days, Duchenne muscular dystrophy, other myopathies, burns, crush injuries, and spinal cord injuries 6

Key Differences

• Rocuronium has a longer duration of action (30-60 minutes) compared to succinylcholine (4-6 minutes) 1, 6
• At 1.2 mg/kg, rocuronium provides similar first-pass success rates to succinylcholine 6
• Rocuronium has fewer adverse effects than succinylcholine—no hyperkalemia risk, no malignant hyperthermia trigger, no postoperative myalgias 6, 7

Essential Safety Measures

Reversal Agent Availability

• Sugammadex must be immediately available when using rocuronium, particularly at higher doses (≥0.9 mg/kg) 1, 6
• This allows rapid reversal in "can't intubate, can't ventilate" scenarios 1

Monitoring Requirements

• Use a peripheral nerve stimulator to confirm adequate neuromuscular blockade before intubation attempt 2
• Ensure facilities for intubation, mechanical ventilation, oxygen therapy, and antagonist are immediately available 2

Post-Intubation Management

• Implement protocolized post-intubation analgosedation to prevent awareness during the prolonged neuromuscular blockade 6
• Apply at least 5 cmH2O PEEP after intubation to improve oxygenation 4

Common Pitfalls and How to Avoid Them

Medication Errors

• Accidental administration of rocuronium can be fatal—store with cap and ferrule intact to prevent wrong-drug errors 2
• Never administer rocuronium without immediately available airway management capabilities 2

Inadequate Sedation

• Failure to provide adequate sedation before paralysis results in awareness during paralysis 4
• Always confirm loss of consciousness before administering rocuronium 1

Premature Intubation Attempt

• Attempting intubation before 60 seconds may result in inadequate relaxation and poor intubating conditions 2
• Use peripheral nerve stimulator to confirm adequate blockade if uncertain 2

Hemodynamic Instability

• Have vasopressors immediately available for managing potential hypotension during RSI 1
• In patients with depleted catecholamine stores, even ketamine may paradoxically cause hypotension 1

Special Populations

Pediatric Patients

• Rocuronium is not recommended for rapid sequence intubation in pediatric patients per FDA labeling 2
• If used in children, ensure sugammadex is rapidly available for reversal 6

Cesarean Section

• Rocuronium is not recommended for rapid sequence induction in patients undergoing Cesarean section 2

Renal or Hepatic Failure

• Do not modify the initial dose of rocuronium in renal or hepatic failure—onset time remains unchanged despite prolonged duration 6