What is the evidence behind varying doses of rocuronium and time to successful intubation?

Posted on May 7, 2020 by Tomas Rapaport

Summary

Clinical trials indicate that time to intubation does not statistically change with increasing doses of rocuronium (0.6-1.2 mg/kg), while other clinical effects of rocuronium increase significantly with increasing doses. Given this data, it is recommended to attempt intubation 1 minute after administration of rocuronium.

I.   FDA rocuronium label (1):

  • Recommends using 0.6-1.2  mg/kg to achieve excellent or good intubation conditions in most patients in under 2 minutes
  • Clinical data is presented below which shows time to completion of intubation with different doses. Note is made of increasing duration of clinical effects with increasing doses while time there is no statistical difference in time to ≥80% block with increasing doses (See Figures 1 and 2 on original document for statistical data)

 

II.   Cochrane Review 2017 (2):

  • Looked at 50 studies that used at least 0.6 mg/kg of rocuronium and most studies allowed 60 seconds between administration of paralytic agent and attempt at intubation, although 2 studies on emergency intubations were placed in a < 60 second subgroup
  • While the dose of rocuronium has been thought to be important in creating improved intubating conditions, there was no statistical significant difference in the proportion of excellent or acceptable intubating conditions between groups receiving 0.6-0.7 mg/kg, or 0.9-1.0 mg/kg, or 1.2 mg/kg of rocuronium 
  • They state that drawing any conclusions based on studies using higher doses of rocuronium (1.2mg/kg) is difficult as sample sizes are low and adverse outcomes may become more prevalent as clinical effect will last a median time of 73 minutes
  • In the < 60 second subgroup, succinylcholine is superior to rocuronium at any dose unless succinylcholine is contraindicated
  • Because most studies allowed 60 seconds to intubation, the authors don’t specifically comment on changes in time to intubation with varying doses of rocuronium

 

Note: other relevant studies were omitted from this summary once it was recognized that they were already included in the Cochrane review and results were congruent with those in the Cochrane review

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. Food and Drugs Administration. Rocuronium Bromide Injection Package Insert [Internet]. United States of America; [cited 2020 May 5]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/078717s000lbl.pdf
  2. Tran DTT, Newton EK, Mount VAH, Lee JS, Mansour C, Wells GA, et al. Rocuronium vs. succinylcholine for rapid sequence intubation: a Cochrane systematic review. Anaesthesia. 2017 May 9;72(6):765–77.

Disclaimer

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