Cisatracurium

Cisatracurium is a prescription medication used for neuromuscular blockade as an adjunct to general anesthesia to facilitate tracheal intubation or skeletal muscle relaxation during surgery. 

• Cisatracurium is available under the following different brand names: Nimbex.

Adult and pediatric dosage

Injectable solution

• 2mg/mL (multidose vial)
• Contains benzyl alcohol
• The injectable solution, preservative-free
• 2mg/mL (single-dose vial)
• 10mg/mL (single-dose vial)

Neuromuscular Blockade

Adult dosage

Initial dose

• In conjunction with propofol or thiopental/nitrous oxide/oxygen induction technique.
• 0.15-0.2 mg/kg IV bolus initially
• Doses up to 0.4 mg/kg IV bolus have been safely administered to healthy patients and patients with serious cardiovascular disease

Maintenance dose, intermittent

• 0.03 mg/kg IV bolus; start 40-50 minutes (after initial dose of 0.15 mg/kg) or 50-60 minutes (after initial dose of 0.2 mg/kg)

Maintenance dose, continuous infusion

• Infuse at 3 mcg/kg/minute initially; subsequently, reduce the rate to 1-2 mcg/kg/minutes to maintain the neuromuscular blockade

Tracheal Intubation

Pediatric dosage

• Children 1 month-23 months: 0.15 mg/kg IV bolus
• Children 2-12 years: 0.1-0.15 mg/kg IV bolus

Skeletal Muscle Relaxation During Surgery

Pediatric dosage

• Indicated for children aged 2 years or older
• Infuse at 3 mcg/kg/minute initially; subsequently, reduce the rate to 1-2 mcg/kg/min to maintain the neuromuscular blockade

Dosage Considerations – Should be Given as Follows: 

• See “Dosages”.

Common side effects of Cisatracurium include:

• slow heart rate, 
• dizziness, and
• flushing (warmth, redness, or tingly feeling)

Serious side effects of Cisatracurium include:

• hives, 
• difficulty breathing, 
• swelling in the face, lips, tongue, or throat, and
• loss of movement in any part of the body

Rare side effects of Cisatracurium include:

• none 

If your medical doctor is using this medicine to treat your pain, your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor, health care provider, or pharmacist first

• Cisatracurium has severe interactions with no other drugs. 
• Cisatracurium has serious interactions with at least 29 other drugs.
• Cisatracurium has moderate interactions with at least 108 other drugs.
• Cisatracurium has minor interactions with at least 39 other drugs.

This information does not contain all possible interactions or adverse effects. Visit the RxList Drug Interaction Checker for any drug interactions. Therefore, before using this drug, tell your doctor or pharmacist of all the drugs you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist. Check with your physician if you have health questions or concerns.

Contraindications

• Hypersensitivity to Cisatracurium (or benzyl alcohol if 10 mL vial is used)
• Use of 10 mL vial in pediatric patients younger than 1 month of age and low birth weight infants (contains benzyl alcohol)

Effects of drug abuse

• None

Short-Term Effects

• See “What Are Side Effects Associated with Using Cisatracurium?”

Long-Term Effects

• See “What Are Side Effects Associated with Using Cisatracurium?”

Cautions

• Laudanosine, an active metabolite, reported to cause seizures in animals; patients with renal or hepatic impairment receiving extended therapy may be at higher risk of seizures; monitor level of neuromuscular blockade during long-term administration to limit exposure to toxic metabolites
• Severe anaphylactic reactions to neuromuscular blocking agents have been reported; some cases have been life-threatening and fatal; take necessary precautions, such as the immediate availability of appropriate emergency treatment
• Confirm proper selection of intended product and avoid confusion with other injectable solutions that are present in critical care and other clinical settings; ensure that the intended dose is clearly labeled and communicated when another healthcare provider is administered
• Neuromuscular blockade in the conscious patient can lead to distress; use the drug in presence of appropriate sedation or general anesthesia and monitor patients to ensure a level of anesthesia is adequate
• The 20-mL vials contain no preservatives and are intended only for IV infusion in a single patient in the ICU; not to be used as a multidose vial for different patients because there is a higher risk of infection
• Not studied in malignant hyperthermia (MH)-susceptible patients; MH can develop in absence of established triggering agents; prepare to recognize and treat MH in any patient undergoing general anesthesia

Residual paralysis

• Residual paralysis has been associated with therapy
• Lower maximum initial bolus in patients at higher risk of residual paralysis (eg, patients with neuromuscular diseases, carcinomatosis)
• Extubation is recommended only after the patient has recovered sufficiently from neuromuscular blockade
• Consider the use of a reversal agent especially in cases where residual paralysis is more likely to occur

Risk of serious adverse reactions in infants due to benzyl alcohol

• Serious and fatal adverse reactions including “gasping syndrome” can occur in neonates and infants treated with benzyl alcohol-containing drugs
• Multidose 10-mL vials contain benzyl alcohol; not applicable in single-dose 5-mL or 20-mL vials
• “Gasping syndrome” is characterized by CNS depression, metabolic acidosis, and gasping respirations
• Use of 10-mL vials is contraindicated in infants younger than 1 month or who have low birth-weight

Drug interaction overview

Succinylcholine

• Use of succinylcholine before Cisatracurium administration may decrease the onset of the maximum neuromuscular blockade but has no effect on the duration of neuromuscular blockade

Inhalational anesthetics

• Administration of inhalational anesthetics with nitrous oxide/oxygen for more than 30 min to achieve 1.25 minimum alveolar concentration may prolong the duration of action of initial and maintenance doses; may potentiate the neuromuscular blockade

Potentiation of neuromuscular blockade

• Certain drugs may enhance neuromuscular blocking action including inhalational anesthetics, antibiotics, magnesium salts, lithium, local anesthetics, procainamide, and quinidine
• Additionally, acid-base and/or serum electrolyte abnormalities may potentiate the action of neuromuscular blocking agents
• Use peripheral nerve stimulation; monitor clinical signs of neuromuscular blockade and adjust the dose, if necessary

Resistance to neuromuscular blockade with certain drugs

• Shorter durations of neuromuscular block may occur; may require higher infusion rates in patients chronically administered phenytoin or carbamazepine
• Use peripheral nerve stimulation and monitor the clinical signs of neuromuscular blockade

Pregnancy and Lactation

• There are no adequate and well-controlled studies in pregnant women; animal studies conducted in rats administered Cisatracurium besylate during organogenesis found no evidence of fetal harm at 0.8 times (ventilated rats) the exposure from a human starting IV bolus dose of 0.2 mg/kg

Labor or delivery

• The action of neuromuscular blocking agents may be enhanced by magnesium salts administered for the management of preeclampsia or eclampsia of pregnancy. 
• It is not known whether a drug is present in human milk; developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for therapy and any potential adverse effects on the breastfed child from treatment or underlying maternal condition