Rocuronium dose and first-attempt intubation success in the critically ill: secondary analysis of two multicenter trials
Year: 2026
Type: article
Abstract: RATIONALE: The neuromuscular blockade dose may affect intubation success on the first attempt, thereby impacting outcomes for patients undergoing emergency tracheal intubation. OBJECTIVES: To evaluate the association between rocuronium dose and tracheal intubation outcomes among adults undergoing emergency tracheal intubation in the emergency department (ED) and intensive care unit (ICU). METHODS: We conducted a secondary analysis of data from two multicenter randomized controlled trials studying airway management in the ED and ICU. We compared patient characteristics and intubation outcomes between patients receiving high-dose (>1.2 mg/kg) versus standard-dose (≤1.2 mg/kg) rocuronium. The primary outcome was successful intubation on the first attempt. We used propensity matching to account for measured potential confounders, stratified by setting. MEASUREMENTS AND MAIN RESULTS: Participating sites included 9 EDs and 24 ICUs in the United States. Among 2440 patients in the trial datasets, we included the 1822 (74.7%) patients who received rocuronium in the current analysis. Of these, 720 (39.5%) received high-dose rocuronium, and 1102 (60.5%) received standard-dose rocuronium. Participants receiving high-dose rocuronium had a higher probability of successful intubation on the first attempt (adjusted relative risk [RR] 1.07, 95% confidence interval [CI] 1.02-1.12). This difference in the primary outcome was not present for ED intubations (adjusted RR 0.97, 95% CI 0.89-1.04) but was present for ICU intubations (adjusted RR 1.13, 95% CI 1.06-1.20). CONCLUSIONS: In this secondary analysis, high-dose rocuronium (>1.2 mg/kg) was associated with higher first-attempt success. Given the potential for unmeasured confounding, these findings warrant evaluation in a randomized controlled trial.
Authors: Michael D April, Harris Butler, Stephanie C Demasi, Neil R Aggarwal, Luke J Andrea, Andrew B Barker, Christopher R Barnes, Jason C Brainard, Joseph Michael Brewer, Brian E Driver, John P Gaillard, Sheetal Gandotra, Shekhar A Ghamande, Kevin W Gibbs, James Taylor Herbert, Christopher G Hughes, David R Janz, Aaron M Joffe, Akram Khan, Patrick J Kramer, Andrew J Latimer, Steven H Mitchell, Ari L Moskowitz, David B Page, Matthew E Prekker, Daniel Resnick-Ault, Wesley H Self, Lane M Smith, Peter D Sottile, Susan B Stempek, Stacy A Trent, Derek J Vonderhaar, James E Walker, Heath D White, Matthew W Semler, Jonathan D Casey, Steven G Schauer, Adit A Ginde
Institutions: Brooke Army Medical Center, Uniformed Services University of the Health Sciences, University of Colorado Anschutz, University of Colorado Denver, Vanderbilt University Medical Center, Montefiore Medical Center, University of Alabama at Birmingham, UAB Medicine, Harborview Medical Center, University of Mississippi Medical Center, Hennepin County Medical Center, Wake Forest University Health Sciences, Wake Forest University, University of Maryland, Baltimore, Baylor Scott & White Medical Center - Temple, Baylor Scott & White Health, Duke University, Duke Medical Center, University Medical Center New Orleans, Creighton University, Oregon Health & Science University, The Ohio State University Wexner Medical Center, University of Washington, Vanderbilt University, Carolinas Medical Center, University of Colorado Hospital, Lahey Hospital and Medical Center, Lahey Medical Center, Denver Health Medical Center, Louisiana State University Health Sciences Center New Orleans, Louisiana State University, United States Army Institute of Surgical Research
Language: English
Subfield: Anesthesiology and Pain Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W7161541626