Comparison of Standard- and High-Dose Rocuronium on Time to Sedation Following Rapid Sequence Intubation in the Emergency Department

Standard dosing for rocuronium in rapid sequence intubation (RSI) is 0.6 to 1.2 mg/kg, based on ideal body weight (IBW). Higher doses, 1.5 to 2 mg/kg, are commonly used in practice and have been associated with higher first-pass success rates and increased probability of improved intubation conditions. These high rocuronium doses are also associated with a dose-dependent increase in duration of paralysis up to 120 minutes. Prolonged paralysis may increase the risk of suboptimal post-intubation sedation by masking musculoskeletal signs of agitation. This study evaluated whether high doses of rocuronium influenced the time to initiation of post-intubation sedation.

This single-center, retrospective study was conducted in the emergency department of an academic medical center. Adult patients with a documented procedure for intubation between January 2022 and June 2024 were included if they received rocuronium during induction. High-dose rocuronium was defined as greater than or equal to 1.5 mg/kg IBW. The primary outcome was time from intubation to initiation of post-intubation sedation. Secondary outcomes included first-pass intubation success, additional sedative use, pharmacist presence, initial Richmond Agitation Sedation Scale (RASS) score post-intubation, incidence of hypotension post-intubation, duration of mechanical ventilation, and hospital length of stay. Data were analyzed using Mann-Whitney U tests for continuous variables and chi-square or Fisher’s exact tests for categorical variables, with significance set at p<0.05.

A total of 136 patients were included, of which 60 patients were in the standard-dose rocuronium group and 76 in the high-dose rocuronium group. Median weight-based dose in the standard-dose group was 1.3 mg/kg and in the high dose group was 1.8 mg/kg. There was no significant difference between the time to post-intubation sedation between the standard- and high-dose groups (23.8 versus 27.1 minutes, p=0.984). Results remained nonsignificant after exclusion of outliers. Secondary outcomes revealed no differences in first-pass intubation success, need for additional sedation, hemodynamic stability, or length of hospital stay between the groups.

In patients receiving rocuronium during RSI, doses greater than or equal to 1.5 mg/kg were not associated with a significant difference in time to post-intubation sedation.