What is the recommended rocuronium dose for intubation in adults and children, including adjustments for rapid‑sequence induction, hepatic dysfunction, renal impairment, and elderly patients, and what are alternative agents and reversal options?

Rocuronium Dosing for Intubation

Standard Intubation Dosing in Adults

For rapid sequence intubation in adults, rocuronium should be dosed at 1.0–1.2 mg/kg to achieve optimal intubating conditions within 60 seconds, with doses ≥1.4 mg/kg associated with higher first-attempt success rates when using direct laryngoscopy. 1, 2, 3

• The minimum effective dose for RSI is 0.9 mg/kg, which provides intubation conditions comparable to succinylcholine 4, 1
• Doses of 0.6 mg/kg are insufficient for RSI and result in suboptimal intubation conditions 1
• Rocuronium 1.2 mg/kg should be administered as early as practical after induction to minimize apnea time and reduce coughing risk 1
• Wait at least 60 seconds after rocuronium administration before attempting intubation, or use peripheral nerve stimulator to confirm complete blockade 1, 2

Evidence for Higher Dosing

• A large registry study (8,034 patients) demonstrated that rocuronium ≥1.4 mg/kg was associated with significantly higher first-attempt success (92.2%) compared to standard 1.0–1.1 mg/kg dosing (88.1%) when direct laryngoscopy was used, with an adjusted odds ratio of 1.9 (95% CI 1.3–2.7) 3
• This higher success rate occurred without any increase in adverse events or desaturation rates 3
• The benefit of higher dosing was particularly pronounced in hypotensive patients (SBP <100 mmHg), who achieved 94.9% first-attempt success with higher doses versus 88.6% with standard dosing 3

Pediatric Dosing

In children requiring rapid sequence induction, rocuronium must be dosed at >0.9 mg/kg when used as an alternative to succinylcholine. 1

• The American Academy of Pediatrics recommends 0.1 mg/kg for routine paralysis and 0.2 mg/kg for standard intubation in pediatric patients 1
• For RSI scenarios where succinylcholine is contraindicated (malignant hyperthermia history, muscular dystrophy, congenital myopathies), use rocuronium >0.9 mg/kg 4, 1

Special Population Adjustments

Elderly Patients (≥80 Years)

Rocuronium 0.9 mg/kg is recommended in elderly patients to ensure adequate onset time and intubating conditions, despite prolonged duration of action. 5

• A randomized trial in patients >80 years demonstrated that 0.3 mg/kg resulted in inadequate blockade (66% failed to achieve TOF count of 0) and prolonged onset time (228 seconds vs 108 seconds with 0.9 mg/kg) 5
• Duration of action is prolonged in elderly patients: 118 minutes with 0.9 mg/kg versus 46 minutes with 0.3 mg/kg 5
• Do not reduce the initial dose in elderly patients, but expect longer recovery times 1, 6
• Sugammadex efficacy may be decreased in elderly patients, particularly for deep blockade reversal 4

Hepatic Dysfunction

The initial rocuronium dose does not require modification in hepatic failure, as onset time remains unchanged despite prolonged duration of action. 1

• Plasma clearance is not significantly influenced by hepatic dysfunction 6
• Consider using benzylisoquinoline muscle relaxants (atracurium/cisatracurium) instead for prolonged procedures in severe hepatic disease 7

Renal Impairment

The initial rocuronium dose does not require modification in renal failure, though duration of action will be extended. 1

• Rocuronium clearance is reduced in severe renal failure (creatinine clearance <30 mL/min): 41.8 mL/min versus 167 mL/min in controls 8
• Only 4% of rocuronium is excreted in urine over 72 hours in renal patients versus 42% over 24 hours in controls 8
• Sugammadex efficacy is significantly decreased in severe renal failure (clearance 5.5 mL/min vs 95.2 mL/min in controls), especially for deep blockade reversal 4, 8
• For sustained neuromuscular blockade in ICU patients with renal failure, consider atracurium or cisatracurium as alternatives 7

Obese Patients (BMI ≥40 kg/m²)

Rocuronium should be dosed using ideal body weight in obese patients, though optimal dosing requires further investigation. 1

• The guideline recommendation is to use ideal body weight for dose calculations 1
• Suxamethonium provides excellent intubating conditions when dosed at 1.0 mg/kg based on actual body weight in obese patients 4

Continuous Infusion Dosing

For prolonged procedures, initiate rocuronium infusion at 10–12 µg/kg/min after a 0.6 mg/kg bolus, titrated to maintain TOF count of 1–4 responses. 4

• Maintenance bolus dosing: 25 mg when TOF returns to 2 responses after initial 50 mg bolus 4
• Recovery time after continuous infusion: approximately 60 minutes after stopping infusion 7
• Quantitative neuromuscular monitoring is mandatory during infusion and must continue until TOF ratio ≥0.9 is achieved 7

Reversal Options

Sugammadex Dosing

Sugammadex dose must be adjusted based on depth of blockade at time of reversal to prevent recurarization. 4

• Moderate blockade (TOF count ≥2): sugammadex 2.0 mg/kg achieves reversal (TOF ratio ≥0.9) in <5 minutes 4
• Deep blockade (PTC 1–2 responses): sugammadex 4.0 mg/kg required 4
• Very deep blockade (PTC 0, within 3–15 minutes of rocuronium 1.0–1.2 mg/kg): sugammadex 8.0 mg/kg required 4
• Immediate reversal (for "can't intubate, can't ventilate" scenarios): sugammadex 8.0 mg/kg 4

Critical Reversal Considerations

• Sugammadex should be immediately available when using high-dose rocuronium (≥0.9 mg/kg) for RSI 1, 2
• Inadequate sugammadex dosing may cause recurarization; continue monitoring after reversal 4
• In patients on chronic pyridostigmine therapy, sugammadex is preferred over neostigmine for reversal 7

Alternative Agents

Succinylcholine (1.0–1.5 mg/kg) remains first-line for RSI when no contraindications exist, providing superior onset (30–45 seconds) and shorter duration (5–10 minutes). 1, 2

• Rocuronium is the preferred alternative when succinylcholine is contraindicated 1, 2
• In electroconvulsive therapy, suxamethonium remains the gold standard; rocuronium-sugammadex combination is used only when formal contraindications exist 4

Critical Pitfalls to Avoid

• Never use rocuronium 0.6 mg/kg for RSI—this dose produces suboptimal intubation conditions 1
• Never administer rocuronium without ensuring adequate sedation/analgesia—it provides no sedation, analgesia, or amnesia 1, 7
• Never delay post-intubation analgosedation after rocuronium—the 30–60 minute duration outlasts ketamine's dissociative effects, creating a high-risk window for awareness 2
• Implement protocolized post-intubation sedation immediately, ideally with clinical pharmacist involvement 1, 2
• Always flush IV tubing with saline before administering rocuronium after other medications to prevent precipitation 1
• In patients on pyridostigmine, reduce subsequent rocuronium doses by 50–75% (not the initial dose) and use mandatory TOF monitoring 7