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Remifentanil Versus Rocuronium for Optimising Video Laryngoscopy Assisted Tracheal Intubation-The ROCVIDEO Trial
Emil Ørskov Ipsen1, Lars Hyldborg Lundstrøm1,2,3, Åse Lodenius4,5
1Department of Anaesthesiology, Copenhagen University Hospital-North Zealand, Hilleroed, Denmark.
Background:
Routine use of neuromuscular blocking agents (NMBAs) is widely recommended to facilitate tracheal intubation. However, NMBA use is associated with potential adverse effects, including postoperative respiratory complications, intraoperative awareness and anaphylaxis. Bolus remifentanil is an alternative, but evidence supporting its effectiveness on first-pass success when using video laryngoscopy is sparse. We hypothesise that rocuronium reduces failed first-pass and the risk of induction- or airway-management-related complications compared with bolus remifentanil when using a video laryngoscope.
Methods:
ROCVIDEO is a Danish-Swedish, blinded, randomised, controlled trial comparing rocuronium (0.6 mg/kg) with remifentanil (4 μg/kg) at anaesthesia induction for facilitating orotracheal intubation using video laryngoscopy. Eligible adult participants (ASA-class I-III) undergoing general anaesthesia with video laryngoscopy-assisted orotracheal intubation will be randomised to rocuronium or remifentanil in a ratio of 1:1. Anaesthesia will be induced with propofol and optional fentanyl or sufentanil. Intubation will be initiated 120 s after administration of trial medicine. The two co-primary outcomes are: (I) anaesthesia-related adverse events and (II) failed first-pass intubation. Secondary outcomes include patient satisfaction, length of stay in the post anaesthesia care unit and serious adverse events. The trial will randomise 2684 participants to be able to detect a 30% relative risk reduction in failed first pass intubation and anaesthesia-related adverse events, with corresponding power of 80% and 99%, respectively, using a two-sided α of 0.025.
Perspectives:
Given the global volume of tracheal intubation, even small differences may have substantial clinical implications. ROCVIDEO will generate high-quality evidence to inform future guidelines aiming to improve global clinical practice.
Status:
As of 15 June 2026, the trial has randomised 707 participants across 15 sites. Recruitment is expected to be completed in the third quarter of 2027.
Trial Registration:
ClinicalTrials.gov: NCT06564857; EUClinicalTrials.eu: 2025-521405-40-01.
Insights
This study compares rocuronium versus remifentanil for tracheal intubation using video laryngoscopy. It aims to determine which agent reduces failed first-pass intubation and anesthesia-related adverse events.
Area of Science:
- Anesthesiology
- Airway Management
- Clinical Trials
Background:
- Neuromuscular blocking agents (NMBAs) facilitate tracheal intubation but carry risks like respiratory complications and anaphylaxis.
- Bolus remifentanil is an alternative, yet its efficacy with video laryngoscopy for first-pass success is not well-established.
- The ROCVIDEO trial investigates the safety and efficacy of rocuronium compared to remifentanil for intubation.
Purpose of the Study:
- To compare the effectiveness of rocuronium versus remifentanil in reducing failed first-pass tracheal intubation.
- To evaluate the incidence of anesthesia-related adverse events associated with each agent during video laryngoscopy-assisted intubation.
- To assess secondary outcomes including patient satisfaction and post-anesthesia care unit length of stay.
Main Methods:
- A blinded, randomized, controlled trial (ROCVIDEO) involving 2684 adult participants (ASA-class I-III).
- Participants receive either rocuronium (0.6 mg/kg) or remifentanil (4 μg/kg) for anesthesia induction prior to video laryngoscopy-assisted orotracheal intubation.
- Co-primary outcomes include failed first-pass intubation and anesthesia-related adverse events, with a two-sided alpha of 0.025.
Main Results:
- Recruitment is ongoing, with 707 participants randomized across 15 sites as of June 15, 2026.
- Full results are pending completion of participant recruitment in Q3 2027.
- The study is powered to detect a 30% relative risk reduction in failed first-pass intubation and anesthesia-related adverse events.
Conclusions:
- The ROCVIDEO trial will provide high-quality evidence on the optimal agent for tracheal intubation.
- Findings are expected to inform clinical guidelines and improve global airway management practices.
- Even small differences in intubation success rates can have significant clinical implications globally.
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