Category: Critical Care
Keywords: intubation, sedation, rapid sequence intubation, RSI, rocuronium, succinylcholine, etomidate, ketamine, propofol (PubMed Search)
Posted: 8/12/2025 by Kami Windsor, MD
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Whether you agree or disagree that “roc rocks and succ sucks,” evidence shows that approximately 3-4% of intubated patients experience awareness while paralyzed [1,2], and more of these patients are in the rocuronium subgroup [2,3,4]. Rocuronium acts in a dose-dependent fashion; the relatively standard 1-1.2 mg/kg in emergency department rapid sequence intubation (RSI) can result in a duration of paralysis can of up to 60-90 minutes. Commonly used sedatives in RSI, however, such as etomidate and ketamine, wear off quickly, before before rocuronium's paralytic effects have abated.
A recent single-center study showed that the majority of patients (60%) receiving rocuronium for paralysis during rapid sequence intubation (RSI) received no additional sedation until more than 15 minutes after induction, whether in the ED or ICU [5].
Patients experiencing awareness during paralysis with post-traumatic stress disorder [1,2] including distress from being restrained, feeling procedures, and feeling of impending death.
Bottom line: Start appropriate dose sedation promptly after RSI, especially with rocuronium, to avoid short- and long-term distress to patients.
