Rocuronium (Anaesthesia/RSI)

How it works

It competitively blocks nicotinic acetylcholine receptors at the neuromuscular junction to produce skeletal muscle relaxation; at higher RSI doses its onset approaches that of suxamethonium, providing rapid intubating conditions without depolarising muscle.

Prescribing in practice

• It provides paralysis with no sedation or analgesia, so it must follow an adequate induction agent and never be given to a conscious patient; failed intubation can be managed because its block can be rapidly reversed with sugammadex.
• Anaphylaxis to neuromuscular blockers is a recognised cause of perioperative anaphylaxis, and rocuronium is among the more frequently implicated agents.
• Duration is prolonged in hepatic impairment and the elderly; neuromuscular monitoring should guide further dosing and confirm adequate reversal before extubation.

Monitoring

Monitor the neuromuscular block with a peripheral nerve stimulator to time intubation, redosing and reversal.

Counselling the patient

• This drug rapidly relaxes the muscles to allow a breathing tube to be placed safely, and is always given after an anaesthetic that ensures the patient is asleep.
• A specific reversal agent is available if the block needs to be undone quickly.
• Muscle strength is checked before the breathing tube is removed.

Evidence & guidelines

Rocuronium at RSI doses provides intubating conditions comparable to suxamethonium and, with sugammadex available for rapid reversal, is widely used for RSI in current UK anaesthetic practice.