Written by Vivian Lei
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Rocuronium doses >1.2 mg/kg improved first-pass intubation success compared with standard dosing but did not affect downstream clinical outcomes.
Go big or go home: rocuronium dosing for RSI
Rocuronium is a commonly used neuromuscular blocking agent for rapid sequence intubation (RSI), but the optimal dosing strategy remains uncertain. Although doses of at least 1.2 mg/kg have been suggested to provide faster onset and better intubating conditions, clinical practice varies widely, and evidence supporting higher dosing is limited.
In this study, the researchers performed a single-center retrospective cohort study evaluating whether rocuronium doses greater than 1.2 mg/kg improve RSI success compared with standard dosing (≤1.2 mg/kg) in adult emergency department and ICU patients undergoing video laryngoscopy. The primary outcome was first-attempt intubation success. The study included 154 intubations in 144 patients. Compared with standard dosing (mean 1.0 mg/kg), higher-dose rocuronium (mean 1.5 mg/kg) was associated with a significantly higher first-pass success rate (100% vs. 89.5%, p<0.01) and slightly fewer intubation attempts. There were no differences in time to successful intubation, ICU or hospital length of stay, or 30-day mortality. Subgroup analyses found no advantage to higher dosing in patients with obesity, sepsis, or heart failure.
Although this was a retrospective, single-center study with a relatively small sample size, the results support considering rocuronium doses of at least 1.2 mg/kg for routine RSI using video laryngoscopy.
How will this change my practice?
Unlike The Princess Bride, where ‘mostly dead’ has its advantages, there isn’t much benefit to being ‘mostly paralyzed.’ When paralysis is the goal, an appropriate RSI dose of 1.2–1.5 mg/kg appears to provide the best intubating conditions. For clinicians who currently use rocuronium doses closer to 1.0 mg/kg, this study provides additional evidence that a full RSI dose may improve first-pass intubation success.
Source
Rocuronium dosing for rapid sequence intubation: A retrospective analysis in ED and ICU settings. Am J Emerg Med. 2026 Jun 23;109:75-80. doi: 10.1016/j.ajem.2026.06.038. Epub ahead of print. PMID: 42385663.
