What are the recommended rocuronium doses for rapid‑sequence intubation in adults and children, including onset, duration, contraindications, and sugammadex reversal?

Rocuronium for Rapid-Sequence Intubation

For rapid-sequence intubation, administer rocuronium 1.0–1.2 mg/kg IV in adults and >0.9 mg/kg in children to achieve intubation conditions within 60 seconds comparable to succinylcholine, with sugammadex immediately available for reversal. 1, 2

Dosing Recommendations

Adults

• Standard RSI dose: 1.0–1.2 mg/kg IV (preferably 1.2 mg/kg for optimal conditions) 1, 2
• The 0.9 mg/kg dose is acceptable but may provide suboptimal intubation conditions; doses <0.9 mg/kg should be avoided in RSI scenarios 2, 3
• Onset time: approximately 60 seconds at 1.2 mg/kg, comparable to succinylcholine's 50 seconds 4
• Duration of action: 30–60 minutes (versus 4–6 minutes for succinylcholine) 1, 3

Pediatric Patients

• RSI dose: >0.9 mg/kg when used as an alternative to succinylcholine 5, 2
• The French guidelines specifically recommend doses >0.9 mg/kg for good intubation conditions in children 5
• A study using 1.2 mg/kg rocuronium in pediatric emergency surgery demonstrated intubation completion in <60 seconds comparable to succinylcholine 1.5 mg/kg 6

Special Populations

• Obese patients: calculate dose using actual body weight, not ideal body weight 1
• Renal or hepatic failure: do not modify the initial dose; onset time remains unchanged despite prolonged duration of action 2, 3
• Severe traumatic brain injury: rocuronium is preferred over succinylcholine due to mortality data showing 23% mortality with rocuronium versus 44% with succinylcholine (OR 4.10,95% CI 1.18–14.12) 1

Onset and Intubation Conditions

• First-pass intubation success: approximately 79% with rocuronium 1.2 mg/kg versus 82–84% with succinylcholine 1, 3
• Rocuronium 0.9–1.2 mg/kg provides excellent intubating conditions within 60 seconds with minimal cardiovascular effects 2, 4
• A Cochrane meta-analysis found that when rocuronium >0.9 mg/kg is compared to succinylcholine 1.0 mg/kg, no superiority of succinylcholine was demonstrated 2
• Wait 60 seconds after administration before attempting intubation, or use peripheral nerve stimulator to confirm full neuromuscular blockade 2

Indications for Rocuronium Over Succinylcholine

Rocuronium should be used when succinylcholine is absolutely contraindicated: 5, 1, 3

• Personal or family history of malignant hyperthermia
• Skeletal muscle myopathies (Duchenne or Becker muscular dystrophy, congenital myopathies)
• Acute phase of injury (24 hours to 7–10 days) after major burns, extensive trauma, or denervation
• Upper motor neuron injury or spinal cord injury
• Prolonged immobilization (>3 days)
• Any neuromuscular disease predisposing to acetylcholine receptor up-regulation
• Severe traumatic brain injury (based on mortality data)

Sugammadex Reversal

• Sugammadex must be immediately available whenever rocuronium is used 1, 2, 3
• Standard reversal doses: 2 mg/kg when train-of-four count ≥2; 4 mg/kg when train-of-four count <2 but posttetanic count ≥1 7
• A dose-finding study demonstrated that 87% of patients required less than the recommended dose when titrated to effect, but 13% required more (range 0.43–5.6 mg/kg) 7
• Quantitative twitch monitoring is essential to confirm adequate reversal; recurrent paralysis occurred in 2% of patients in one study 7
• In elderly patients and those with severe renal failure, sugammadex efficacy may be decreased, particularly with deep blockade 2

Critical Post-Intubation Management

Implement protocolized post-intubation analgosedation immediately after rocuronium administration to prevent intra-procedural awareness during the 30–60 minute paralysis window. 1, 2, 3

• The longer duration of rocuronium compared to succinylcholine may prevent patient movement that would otherwise alert staff to provide sedation 2
• Clinical pharmacist involvement improves timely delivery of sedation and analgesia 1
• Rocuronium provides no sedation, analgesia, or amnesia; appropriate sedative/analgesic agents must be administered concurrently 2

Administration Technique

• Administer rocuronium as early as practical after induction to minimize apnea time and reduce coughing risk 2
• Always flush IV tubing with saline before administering rocuronium after other medications to avoid precipitation and IV obstruction 2
• Personnel with airway management skills must be present and prepared to respond 2
• Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation must be immediately available 2

Common Pitfalls and How to Avoid Them

• Underdosing: Do not use <0.9 mg/kg for RSI; this results in suboptimal intubation conditions 2, 3
• Premature intubation attempt: Wait the full 60 seconds or confirm complete blockade with nerve stimulator before laryngoscopy 2
• Forgetting post-intubation sedation: The prolonged paralysis (30–60 minutes) mandates immediate sedation protocols to prevent awareness 1, 2
• Assuming sugammadex always works at standard doses: Quantitative monitoring is essential; some patients require higher doses and recurrent paralysis can occur 7
• Using ideal body weight in obese patients: Calculate dose using actual body weight 1

Comparative Evidence: Rocuronium vs. Succinylcholine

The European Society of Anaesthesiology and Intensive Care continues to endorse succinylcholine as first-line for RSI despite sugammadex availability, because succinylcholine offers unmatched rapid onset and very short duration 1. However, the French guidelines conclude that rocuronium should be used when succinylcholine is contraindicated, with the choice based on desired duration of muscle relaxation, risk of difficult intubation, and presence of neuromuscular disease 5.

A large out-of-hospital randomized controlled trial found first-pass success rates of 79.4% with succinylcholine 1.0 mg/kg versus 74.6% with rocuronium 1.2 mg/kg, demonstrating comparable efficacy 3. Adult studies confirm that rocuronium 0.9–1.2 mg/kg produces onset times (55–75 seconds) similar to succinylcholine (50 seconds), though with significantly longer clinical duration 4.