cisatracurium (Rx)

Neuromuscular Blockade

Indicated as an adjunct to general anesthesia to facilitate tracheal intubation

Also indicated for skeletal muscle relaxation during surgical procedures or mechanical ventilation in ICU settings

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 min (after initial dose of 0.15 mg/kg) or 50-60 min (after initial dose of 0.2 mg/kg)
• Smaller or larger doses may be administered based on required duration of action
• Consider less frequent or lower maintenance bolus doses for long surgical procedures using inhalational anesthetics administered with nitrous oxide/oxygen at the 1.25 MAC level for at least 30 min
• No adjustment to initial maintenance bolus dose necessary when administered shortly after initiation of volatile agents or used in patients receiving propofol anesthesia

Maintenance dose, continuous infusion

• Use during extended surgical procedures OR during extended need for mechanical ventilation and skeletal muscle relaxation in the ICU if spontaneous recovery occurs after initial bolus dose
• May be necessary to readminister a bolus dose following recovery from neuromuscular blockade to re-establish neuromuscular blockade before starting infusion
• Infuse at 3 mcg/kg/min initially; subsequently reduce rate to 1-2 mcg/kg/min to maintain neuromuscular blockade
• Assess level of neuromuscular blockage using peripheral nerve stimulation and titrate appropriately
• Discontinue if no response is elicited to peripheral nerve stimulation

• Administration during isoflurane anesthesia or other inhalational anesthetics

  • Consider reducing infusion rate by up to 30-40% during stable isoflurane anesthesia for at least 30 min (administered with nitrous oxide/oxygen at the 1.25 MAC level)
  • Longer durations of administration of isoflurane or with administration of other inhalational anesthetics may require greater reductions in infusion rate

Dosage Modifications

Patients with neuromuscular disease

• Includes myasthenia gravis, myasthenic syndrome, carcinomatosis
• Maximum initial dose: 0.2 mg/kg IV bolus

Patients with burn injuries

• Shown to develop resistance to nondepolarizing neuromuscular blocking agents
• Consider increasing dosages for intubation and maintenance

Patients undergoing coronary artery bypass graft (CABG) surgery

• Consider reducing infusion rate for continuous infusions in patients undergoing CABG with induced hypothermia to half the rate required during normothermia
• Spontaneous recovery from neuromuscular block following discontinuation of infusion is expected proceed at a rate comparable to that following administration of a single bolus dose

Patients with hemiparesis or paraparesis

• Patients with hemiparesis or paraparesis may demonstrate resistance to nondepolarizing muscle relaxants in affected limbs
• To avoid inaccurate dosing, perform neuromuscular monitoring on a nonparetic limb

Renal impairment

• End-stage renal disease

  • Consider extending interval between administration and intubation by at least 1 min to achieve adequate intubation
  • Use peripheral nerve stimulator to determine adequate muscle relaxation for intubation and timing/amount of subsequent doses

Hepatic impairment

• End-stage liver disease undergoing liver transplantation

  • Pharmacokinetic study reported slightly larger volume of distribution and plasma concentration of cisatracurium
  • Time to maximum blockade for a 1 mg/kg-dose was ~1 min faster

Dosing Considerations

Before initiating, consider desired time of tracheal intubation, anticipated length of surgery, factor affecting onset of complete neuromuscular block (eg, age, renal function), factors that may influence intubation conditions such as presence of co-induction agents (eg, fentanyl, midazolam), and depth of anesthesia

Limitations of use

• Not recommended for rapid sequence endotracheal intubation due to time required for its onset of action

Tracheal Intubation

Indicated as an adjunct to general anesthesia to facilitate tracheal intubation in adults and in children aged 1 month to 12 years

1-23 months: 0.15 mg/kg IV bolus  

2-12 years: 0.1-0.15 mg/kg IV bolus

Skeletal Muscle Relaxation During Surgery

Indicated for skeletal muscle relaxation during extended surgical procedures via IV infusion in children aged ≥2 years

Maintenance continuous infusion aged >2 years

• Use during extended surgical procedures if spontaneous recovery occurs after initial bolus dose
• May be necessary to readminister a bolus dose following recovery from neuromuscular blockade to re-establish neuromuscular blockade before starting infusion
• Infuse at 3 mcg/kg/min initially; subsequently reduce rate to 1-2 mcg/kg/min to maintain neuromuscular blockade  
• Assess level of neuromuscular blockage using peripheral nerve stimulation and titrate appropriately
• Discontinue if no response is elicited to peripheral nerve stimulation

Administration during isoflurane anesthesia or other inhalational anesthetics

• Consider reducing infusion rate by up to 30-40% during stable isoflurane anesthesia for at least 30 min (administered with nitrous oxide/oxygen at the 1.25 MAC level)
• Longer durations of administration of isoflurane or with administration of other inhalational anesthetics may require greater reductions in infusion rate

Dosage Modifications

Patients with neuromuscular disease

• Includes myasthenia gravis, myasthenic syndrome, carcinomatosis
• Maximum initial dose: 0.2 mg/kg IV bolus

Patients with burn injuries

• Shown to develop resistance to nondepolarizing neuromuscular blocking agents
• Consider increasing dosages for intubation and maintenance

Renal impairment

• End-stage renal disease

  • Consider extending interval between administration and intubation by at least 1 min to achieve adequate intubation
  • Use peripheral nerve stimulator to determine adequate muscle relaxation for intubation and timing/amount of subsequent doses

Hepatic impairment

• End-stage liver disease undergoing liver transplantation

  • Pharmacokinetic study reported slightly larger volume of distribution and plasma concentration of cisatracurium
  • Time to maximum blockade for a 1 mg/kg-dose was ~1 min faster

Dosing Considerations

Before initiating, consider desired time of tracheal intubation, anticipated length of surgery, factor affecting onset of complete neuromuscular block (eg, age, renal function), factors that may influence intubation conditions such as presence of co-induction agents (eg, fentanyl, midazolam), and depth of anesthesia

Limitations of use

• Not recommended for rapid sequence endotracheal intubation due to time required for its onset of action