cisatracurium (Rx)

<1%

Bronchospasm

Bradycardia

Flushing

Pruritus

Myositis ossificans

Hypotension

Rash

Contraindications

Hypersensitivity to cisatracurium (or benzyl alcohol if 10 mL vial is used)

Use of 10 mL vial in pediatric patients <1 month of age and low birth-weight infants (contains benzyl alcohol)

Cautions

Severe anaphylactic reactions to neuromuscular blocking agents have been reported; these reactions have, in some cases, been life threatening and fatal; because of the potential severity of these reactions, the necessary precautions, such as the immediate availability of appropriate emergency treatment, should be taken

Do not administer before unconsciousness

May cause a profound effect in those with myasthenia gravis or the myasthenic syndrome

May require higher doses in burns

Bradycardia may occur

Cross sensitivity with other neuromuscular-blocking agents may occur; use caution in patients with previous anaphylactive reactions to neuromuscular blocking agents

Hepatic impairment: onset time is faster (~1 min) and recovery is slower (~1 min)

Maximum blockage time about 1 min slower in geriatric and renally impaired pts

Therapy has been associated with residual paralysis; patients with neuromuscular diseases (e.g., myasthenia gravis and myasthenic syndrome) and carcinomatosis may be at higher risk; a lower maximum initial bolus is recommended in these patients; use a lower initial bolus dose and consider using a reversal agent in these patients

Consider combined daily load of benzyl alcohol from all sources when the 10 mL multiple dose vials are used in infants

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

Accidental administration can cause death; store drug with cap and ferrule intact and in a manner that minimizes possibility of selecting wrong product

Neuromuscular blockade in the conscious patient can lead to distress; use drug in presence of appropriate sedation or general anesthesia and monitor patients to ensure level of anesthesia is adequate

The 20 mL vial is intended only for administration as an infusion for use in a single patient in the ICU; the 20 mL vial should not be used multiple times because there is a higher risk of infection (the 20 mL vial does not contain a preservative)

Certain drugs may enhance neuromuscular blocking action including inhalational anesthetics, antibiotics, magnesium salts, lithium, local anesthetics, procainamide and quinidine; acid-base and/or serum electrolyte abnormalities may potentiate action of neuromuscular blocking agents; use peripheral nerve stimulation and monitor clinical signs of neuromuscular blockade to determine adequacy of level of neuromuscular blockage and need to adjust dosage

Not studied in malignancy hyperthermia (MH)-susceptible patients; because MH can develop in absence of established triggering agents, clinician should be prepared to recognize and treat MH in any patient undergoing general anesthesia

Pregnancy

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 management of preeclampsia or eclampsia of pregnancy

Lactation

It is not known whether drug is present in human milk; developmental and health benefits of breastfeeding should be considered along with mother's clinical need for therapy and any potential adverse effects on breastfed child from treatment or from underlying maternal condition

Pregnancy Categories

A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

NA: Information not available.

Mechanism of Action

Non-depolarizing skeletal muscle relaxant; cholinergic receptor antagonist; a cis-isomer of atracurium

Pharmacokinetics

Half-Life: 22-29 min

Onset: 2-3 min (IV; mean for 0.15-0.2 mg/kg adult dose)

Duration: 55-65 min

Peak plasma time: 3-5 min

Vd: 145 mL/kg

Metabolism: Forms inactive metabolites

Excretion: Urine 95%

IV Incompatibilities

Solution: LR

Y-site:

• Incompatible: cefoperazone, diazepam(?), ketorolac, propofol
• Incompatible at 5 mg/mL cisatracurium (may be compatible at 2 mg/mL or less): acyclovir, aminophylline, amphotericin B, ampicillin, ampicillin-sulbactam, cefotetan, ceftizoxime, cetazidime (?), ganciclovir, heparin, piperacillin-tazobactam, ticarcillin-clavulanate
• Incompatible at 2 & 5 mg/mL cisatracurium (may be compatible at 0.1 mg/mL): cefazolin, cefotaxime, cefoxitin, cefuroxime, furosemide, methylprednisolone, piperacillin, sodium bicarbonate, sodium nitroprusside, thiopental, trimethoprim-sulfamethoxazole

May be incompatible with highly alkaline drug solutions

IV Preparation

Dilute in D5W, NS or D5/NS

As low as 0.1 mg/mL can be stored at room temp or refrigerated for 24 hr