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

Authors

• Michael D. April, Brooke Army Medical Center, San Antonio, TX
• Harris Butler, University of Colorado School of Medicine, Aurora, CO
• Stephanie C. Demasi, Vanderbilt University Medical Center, Nashville, TN
• Neil Aggarwal, University of Colorado School of Medicine, Aurora, CO
• Luke Andrea, Montefiore Medical Center, Bronx, NY
• Andrew B. Barker, University of Alabama Birmingham, Birmingham, AL
• Christopher R. Barnes, Harborview Medical Center, Seattle, WA
• Jason C. Brainard, University of Colorado School of Medicine, Aurora, CO
• J Michael Brewer, University of Mississippi Medical Center, Jackson, MS
• Brian E. Driver, Hennepin County Medical Center, Minneapolis, MN
• John P. Gaillard, Wake Forest School of Medicine, Winston-Salem, NC
• Sheetal Gandotra, University of Maryland School of Medicine, Baltimore, MD
• Shekhar A. Ghamande, Critical Care, and Sleep Medicine, Baylor Scott & White Health, Temple, TX
• Kevin W. Gibbs, Section on Pulmonary and Critical Care Wake Forest School of Medicine Winston-Salem, NC
• Taylor Herbert, Duke University School of Medicine, Durham, NC
• Christopher G. Hughes, Vanderbilt Medical Center, Nashville, TN
• David R. Janz, University Medical Center New Orleans, New Orleans, LA
• Aaron M. Joffe, Creighton University School of Medicine, Omaha, NE
• Akram Kahn, Oregon Health and Science University, Portland, OR
• Patrick J. Kramer, Ohio State University Medical Center, Columbus, OH
• Andrew J. Latimer, University of Washington School of Medicine, Seattle, WA
• Steven H. Mitchell, University of Washington School of Medicine, Seattle, WA
• Ari Moskowitz, Montefiore Medical Center, Bronx, NY
• David Page, University of Alabama Birmingham, Birmingham, AL
• Matthew E. Prekker, Hennepin County Medical Center, Minneapolis, MN
• Daniel Resnick-Ault, University of Colorado School of Medicine, Aurora, CO
• Wesley H. Self, Vanderbilt University Medical Center, Nashville, TN
• Lane M. Smith, Carolinas Medical Center, Charlotte, NC
• Derek Vonderhaar, LSU Health Sciences Center - New OrleansFollow
• et al

Document Type

Article

Publication Date

5-18-2026

Publication Title

American Journal of Respiratory and Critical Care Medicine

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.

First Page

1

Last Page

34

PubMed ID

42149702

Rights

Public Domain

Recommended Citation

April, Michael D.; Butler, Harris; Demasi, Stephanie C.; Aggarwal, Neil; Andrea, Luke; Barker, Andrew B.; Barnes, Christopher R.; Brainard, Jason C.; Brewer, J Michael; Driver, Brian E.; Gaillard, John P.; Gandotra, Sheetal; Ghamande, Shekhar A.; Gibbs, Kevin W.; Herbert, Taylor; Hughes, Christopher G.; Janz, David R.; Joffe, Aaron M.; Kahn, Akram; Kramer, Patrick J.; Latimer, Andrew J.; Mitchell, Steven H.; Moskowitz, Ari; Page, David; Prekker, Matthew E.; Resnick-Ault, Daniel; Self, Wesley H.; Smith, Lane M.; Vonderhaar, Derek; and al, et, "Rocuronium Dose and First-Attempt Intubation Success in the Critically Ill: Secondary Analysis of Two Multicenter Trials" (2026). School of Medicine Faculty Publications. 4853.
https://digitalscholar.lsuhsc.edu/som_facpubs/4853
10.1093/ajrccm/aamag203