Incidence of Explicit Recall After Rocuronium and Ketamine for RSI
The incidence of explicit recall of intubation in patients receiving rocuronium and ketamine for rapid sequence intubation is approximately 2.6% in emergency intubations, though this rate can be substantially reduced when protocolized post-intubation analgosedation is implemented immediately after the procedure. 1, 2
Understanding the Awareness Risk
The risk of awareness during RSI with rocuronium stems from a critical pharmacokinetic mismatch:
Rocuronium produces neuromuscular blockade lasting 30–60 minutes, while ketamine's dissociative effects wear off much sooner, creating a window where patients may be paralyzed but inadequately sedated. 1
The longer duration of rocuronium compared to succinylcholine (5–10 minutes) may prevent patient movement that would otherwise alert staff to provide additional sedation, making delayed analgosedation a particular concern. 1
Ketamine must always be administered BEFORE the neuromuscular blocking agent to prevent awareness during the paralysis phase itself. 2, 3
Evidence on Post-Intubation Sedation Timing
The most relevant data addressing this concern comes from emergency department practice:
A 2018 study demonstrated that when rocuronium was used for RSI in the ED after a pharmacy-led educational program, there was a median of 2 analgosedative interventions in the first 30 minutes post-RSI versus 0 interventions at 60–90 minutes, with a median time to first intervention of only 7 minutes. 4
This study showed no delay in provision of post-intubation sedation when institutional protocols were in place, suggesting that awareness can be prevented with proper systems. 4
Critical Mitigation Strategies
Institutions must implement protocolized post-intubation analgosedation immediately after RSI with rocuronium, ideally with clinical pharmacist involvement, to prevent the awareness window that occurs when paralysis outlasts sedation. 1, 2
Specific Protocol Elements:
Initiate continuous sedation infusions or repeated boluses within the first 10 minutes post-intubation 4
Assign a dedicated team member (ideally a clinical pharmacist) to manage post-intubation analgosedation timing 1
Use standardized order sets that automatically trigger sedation protocols after rocuronium administration 1
Common Pitfall to Avoid
The most dangerous error is assuming that the initial ketamine dose (1–2 mg/kg) provides adequate sedation throughout the entire duration of rocuronium-induced paralysis—it does not. 1, 2 The dissociative effects of ketamine dissipate well before rocuronium's neuromuscular blockade resolves, creating a high-risk period for awareness if additional sedation is not promptly administered.
Comparative Context
Studies examining awareness have not shown differences in incidence between succinylcholine and rocuronium when optimal analgosedation is prospectively provided by the healthcare team. 1
However, observational data suggest that rocuronium may delay the provision of post-intubation analgosedation compared to succinylcholine, likely because the absence of patient movement fails to cue staff. 1