Rocuronium ≤1.5 mg/kg versus >1.5 mg/kg and inadequate paralysis in prehospital and retrieval intubation: A retrospective study

Objective Greater Sydney Area Helicopter Emergency Medical Service encouraged an increased dose of rocuronium for rapid sequence intubations (RSIs) from 1.5 mg/kg to 2.0 mg/kg from the end of 2017 in response to a number of inadequately paralysed patients identified by our airway audit processes. Subsequent protocol change incorporated 2.0 mg/kg rocuronium. This retrospective observational study was undertaken to see if doses over 1.5 mg/kg rocuronium were associated with a reduction in the number of inadequately paralysed patients. Methods Retrospective review of patient prehospital notes and airway database records from 2017 to 2018 for all cases using rocuronium for RSI. Primary outcome of interest was physician notes describing skeletal muscle activity at laryngoscopy. Patients with tissued vascular access were excluded. Dose of rocuronium, estimated patient actual weight and grade of laryngoscopy were recorded. Comparisons were made between rocuronium doses ≤1.5 mg/kg and >1.5 mg/kg by estimated weight. Results From 211 patients receiving rocuronium ≤1.5 mg/kg, five cases were inadequately paralysed, compared with two cases from 384 patients receiving >1.5 mg/kg rocuronium. Conclusions Although there were fewer inadequately paralysed patients with rocuronium doses >1.5 mg/kg, this did not reach statistical significance, presumably because of the low event rate. Further investigation into rocuronium dose for RSI is warranted.