Rocuronium Dose and First-Attempt Intubation Success in the Critically Ill: Secondary Analysis of Two Multicenter Trials

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• Picked for Emergency Medicine (top studies of the week, 8 November 2026): High‑dose rocuronium improves first‑attempt intubation success

Abstract

RATIONALE: Neuromuscular blockade dose may affect intubation success on the first attempt, thereby impacting outcomes for patients undergoing emergency tracheal intubation. OBJECTIVE: 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 2 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 2,440 patients in the trial datasets, we included the 1,822 (74.7%) patients who received rocuronium in the current analysis. Of these, 720 (39.5%) received high-dose rocuronium and 1,102 (60.5%) received standard-dose rocuronium. Participants receiving high-dose rocuronium had higher probability of successful intubation on the first attempt (adjusted relative risk [RR] 1.06, 95% confidence interval [CI] 1.01-1.11). This difference in the primary outcome was not present for ED intubations (adjusted RR 0.97, 95%CI 0.90-1.04) but was present for ICU intubations (adjusted RR 1.12, 95% CI 1.05-1.19). CONCLUSION: 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.

Abstract as published, via PubMed.