Reexamined: the recommended endotracheal intubating dose for nondepolarizing neuromuscular blockers of rapid onset

The results of any study of the relative importance of anesthetic depth versus intensity of neuromuscular block on conditions for endotracheal intubation can be manipulated by the investigator. Several independent factors, such as the depth of hypnosis induced, the interval between drug administration and laryngoscopy, the onset profile of the muscle relaxant, and the multiple of the 95% effective dose given, must be controlled. We attempted to design an induction sequence that provided good to excellent conditions for laryngoscopy and endotracheal intubation within 75-90 s of muscle relaxant administration with doses smaller than often suggested, while still administering only customary amounts of hypnotics and opioids. Alfentanil 12.5 microg/kg, propofol 2.0 mg/kg, and a test drug were administered rapidly. The test drugs were saline 0.05 mL/kg (n = 10), rapacuronium 1.0 or 1.2 mg/kg, or rocuronium 0.50 mg/kg (n = 30 each). Laryngoscopy was commenced 75 s after the test drug. Clinically acceptable conditions for intubation were achieved in all subjects after rocuronium or rapacuronium 1.2 mg/kg and in 28 of 30 patients after rapacuronium 1.0 mg/kg. In the Saline group, only 3 individuals achieved a good or excellent rating, and intubation was impossible in 2 of 10 individuals. For muscle relaxants of low potency, doses only 1.5 times the 95% effective dose can provide very satisfactory conditions for intubation if laryngoscopy is delayed to 75 s after drug administration. IMPLICATIONS: The dose of muscle relaxant usually recommended for facilitating tracheal intubation approximates at least two times the drug's effective dose (ED(95)). When the muscle relaxant in question has a rapid onset of action, this intubation dose may be decreased to 1.5 times the ED(95).