Cisatracurium Besylate
Pronouncation: (sis-ah trah-CURE-ee-uhm BESS-ih-late)Class: Nondepolarizing neuromuscular blocking agent
Trade Names:
Nimbex
- Injection 2 mg/mL
- Injection 10 mg/mL
Pharmacology
Binds competitively to cholinergic receptors on motor end-plate to antagonize action of acetylcholine, resulting in block of neuromuscular transmission.
Pharmacokinetics
Metabolism
Degradation is mainly caused by hepatic metabolism.
Elimination
Metabolites are eliminated primarily by the liver and kidney.
Special Populations
The times to maximum block were approximately 1 min faster in liver transplant patients compared with healthy adults. The times to 90% block were approximately 1 min slower in patients with end-stage renal disease.
Indications and Usage
Intermediate-onset/intermediate-duration neuromuscular blockade for inpatients and outpatients as adjunct to general anesthesia, to facilitate tracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation.
Contraindications
Hypersensitivity to bis-benzylisoquinolinium agents or any component of the product.
Dosage and Administration
Use of a peripheral nerve stimulator will permit the most advantageous use of cisatracurium and will minimize the possibility of overdosage or underdosage and assist in the evaluation of recovery.
AdultsIV 0.15 and 0.2 mg/kg, as components of a propofol/nitrous oxide/oxygen induction-intubation technique, may produce generally good or excellent conditions for tracheal intubation in 2 and 1.5 min, respectively.
Elderly and Renal Function ImpairmentIV Recommended dose is 0.03 mg/kg for maintenance of neuromuscular block during prolonged surgery, which sustains neuromuscular block for approximately 20 min. Maintenance dosing is generally required 40 to 50 min after an initial dose of 0.15 mg/kg and 50 to 60 min following an initial dose of 0.2 mg/kg.
Children 2 to 12 yr of ageIV Recommended dose is 0.1 mg/kg over 5 to 10 sec during either halothane or opioid anesthesia. When given during stable opioid/nitrous oxide/oxygen anesthesia, 0.1 mg/kg produces maximum neuromuscular block in an average of 2.8 min and clinically effective block for 28 min.
Continuous InfusionAdults and Children (2 yr of age and older)
IV Adjust rate of administration according to the patient's response as determined by peripheral nerve stimulation. Initiate the infusion only after early evidence of spontaneous recovery from the initial bolus dose.
Infusion in ICU or Operating RoomAdults
IV Approximately 3 mcg/kg/min should provide adequate neuromuscular block. Following recovery from neuromuscular block, readministration of a bolus dose may be necessary to quickly re-establish neuromuscular block prior to reinstitution of the infusion.
General Advice
- Follow manufacturer's instructions for preparation and storage of solutions for continuous IV infusion.
- Inspect solution visually before administration. Solution may have a slightly yellow or greenish-yellow color. Do not administer if solution is cloudy, discolored, or contains particulate matter.
Storage/Stability
Store vials in refrigerator (36° to 46°F) in original carton. Do not freeze. May be removed from refrigerator and stored at controlled room temperature (59° to 86°F) but injection must be used within 21 days even if rerefrigerated.
Drug Interactions
Antibiotics (eg, aminoglycoside antibiotics [eg, kanamycin], bacitracin, clindamycin, lincomycin, polymyxins, sodium colistimethate, tetracyclines), lithium, local anesthetics, magnesium salts, procainamide, quinidineMay enhance the neuromuscular blocking action of cisatracurium.
Carbamazepine, phenytoinResistance to neuromuscular blocking action of cisatracurium may occur.
Nitrous oxide/oxygen with either enflurane or isofluraneMay prolong the clinically effective duration of action of initial and maintenance doses of cisatracurium and decrease the required infusion rate.
SuccinylcholineTime of onset of maximum block following cisatracurium is approximately 2 min faster with prior administration of succinylcholine.
Incompatibility
Alkaline solutions with a pH greater than 8.5 (eg, barbiturate solutions); propofol or ketorolac for Y-side administration.
Laboratory Test Interactions
None well documented.
Adverse Reactions
Cardiovascular
Bradycardia, hypotension.
Dermatologic
Rash.
Respiratory
Bronchospasm.
Miscellaneous
Flushing.
Precautions
MonitorRespiratory statusAssess respiratory status frequently. Inform health care provider immediately if deterioration in respiratory status or blood gases are noted. Vital signsMonitor vital signs frequently. Inform health care provider immediately if cardiovascular instability is noted. |
Pregnancy
Category B .
Lactation
Undetermined.
Children
Safety and efficacy not established in children under 2 yr of age.
Elderly
The time of maximum block is approximately 1 min slower in patients over 65 yr of age.
Renal Function
The onset time was approximately 1 min faster in patients with end-stage liver disease and approximately 1 min slower in patients with renal dysfunction compared with healthy adults.
Hepatic Function
The onset time was approximately 1 min faster in patients with end-stage liver disease and approximately 1 min slower in patients with renal dysfunction compared with healthy adults.
Administration
Use under the supervision of experienced clinicians who are familiar with cisatracurium action and complications. Personnel and facilities for resuscitation and life support and an antagonist of cisatracurium should be immediately available.
Benzyl alcohol
The 10 mL multiple-dose vial contains benzyl alcohol, which has been associated with neurological and other complications that are sometimes fatal in neonates.
Endotracheal intubation
Because of intermediate onset, not recommended for use.
Malignant hyperthermia
May occur.
Neuromuscular function
To avoid inaccurate dosing in patient with hemiparesis or paraparesis, monitor neuromuscular function on a nonparetic limb.
Patient distress
Because cisatracurium does not affect consciousness, pain threshold, or cerebration, do not induce neuromuscular block before unconsciousness.
Special populations
May have profound effect in patients with neuromuscular disease (eg, myasthenia gravis). Patients with burns, hemiparesis, or paraparesis may have resistance to cisatracurium. Acid-base or serum electrolyte imbalance may potentiate or antagonize the action of cisatracurium.
Overdosage
Symptoms
Prolonged neuromuscular block.
Patient Information
- Advise patient, family, or caregiver that medication will be prepared and administered by a health care provider in a health care setting.
- Reassure patient, family, or caregiver that breathing will be closely monitored and supported while medication is being administered and that breathing and muscle function will return to normal after medication has been discontinued.
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