No

Neuromuscular Blocker Agent, Nondepolarizing

Drug for neuromuscular blockade in patients with renal and/or hepatic failure; eases endotracheal intubation as an adjunct to general anesthesia and relaxes skeletal muscle during surgery or mechanical ventilation; does not relieve pain

C

Hypersensitivity to cisatracurium besylate or any component

Not recommended for rapid sequence intubation; may produce profound effects in patients with neuromuscular disorders (myasthenia gravis); patients with severe burns may develop resistance; maintenance of an adequate airway and respiratory support is critical

<1%: Effects are minimal and transient, bradycardia and hypotension, flushing, rash, bronchospasm

Symptoms of overdose include respiratory depression, cardiovascular collapse

Neostigmine 1-3 mg slow I.V. push in adults (0.5 mg in children) antagonizes the neuromuscular blockade, and should be administered with or immediately after atropine 1-1.5 mg I.V. push (adults). This may be especially useful in the presence of bradycardia.

Prolonged neuromuscular blockade:

Inhaled anesthetics:

Halothane has only a marginal effect, enflurane and isoflurane increase the potency and prolong duration of neuromuscular blockade induced by cisatracurium

Dosage should be reduced by 30% to 40% in patients receiving isoflurane or enflurane

Local anesthetics

Lithium

Magnesium salts

Antiarrhythmics (eg, quinidine or procainamide)

Antibiotics (eg, aminoglycosides, tetracyclines, vancomycin, clindamycin)

Resistance to neuromuscular blockade: Chronic phenytoin or carbamazepine

Refrigerate intact vials at 2°C to 8°C/36°F to 46°F; use vials within 21 days upon removal from the refrigerator to room temperature (25°C to 77°F). Dilutions of 0.1-0.2 mg/mL in 0.9% sodium chloride or dextrose 5% in water are stable for up to 24 hours at room temperature. Incompatible with sodium bicarbonate, ketorolac, propofol; compatible with alfentanil, droperidol, fentanyl, midazolam, and sufentanil.

Blocks neural transmission at the myoneural junction by binding with cholinergic receptor sites

Onset of action: I.V.: 2-3 minutes

Peak effect: Within 3-5 minutes

Duration: Recovery begins in 20-35 minutes when anesthesia is balanced; recovery is attained in 90% of patients in 25-93 minutes

Metabolism: Some metabolites are active; undergoes rapid nonenzymatic degradation in the bloodstream, additional metabolism occurs via ester hydrolysis

Half-life: 22 minutes

I.V. (not to be used I.M.):

Children 2-12 years: Intubating doses: 0.1 mg over 5-15 seconds during either halothane or opioid anesthesia. ( Note: When given during stable opioid nitrous oxide/oxygen anesthesia, 0.1 mg/kg produces maximum neuromuscular block in an average of 2.8 minutes and clinically effective block for 28 minutes.)

Adults: Intubating doses: 0.15-0.2 mg/kg as components of propofol/nitrous oxide/oxygen induction-intubation technique. ( Note: May produce generally good or excellent conditions for tracheal intubation in 1.5-2 minutes with clinically effective duration of action during propofol anesthesia of 55-61 minutes.)

Children greater than or equal to 2 years and Adults: Continuous infusion: After an initial bolus, a diluted solution can be given by continuous infusion for maintenance of neuromuscular blockade during extended surgery; adjust the rate of administration according to the patient's response as determined by peripheral nerve stimulation. An initial infusion rate of 3 mcg/kg/minute may be required to rapidly counteract the spontaneous recovery of neuromuscular function; thereafter, a rate of 1-2 mcg/kg/minute should be adequate to maintain continuous neuromuscular block in the 89% to 99% range in most pediatric and adult patients. Consider reduction of the infusion rate by 30% to 40% when administering during stable isoflurane or enflurane anesthesia. Spontaneous recovery from neuromuscular blockade following discontinuation of infusion of cisatracurium may be expected to proceed at a rate comparable to that following single bolus administration.

Intensive care unit administration: Follow the principles for infusion in the operating rooms. An infusion rate of ~3 mcg/kg/minute should provide adequate neuromuscular blockade in adult patients. Following recovery from neuromuscular block, readministration of a bolus dose may be necessary to quickly re-establish neuromuscular block prior to reinstituting the infusion; dosage ranges of 0.5-10 mcg/kg/minute have been reported.

Dosing adjustment in renal impairment: Because slower times to onset of complete neuromuscular block were observed in renal dysfunction patients, extending the interval between the administration of cisatracurium and intubation attempt may be required to achieve adequate intubation conditions.

Give undiluted as a bolus injection; not for I.M. inject, too much tissue irritation; continuous administration requires the use of an infusion pump

Vital signs (heart rate, blood pressure, respiratory rate)

May be difficult to talk because of head and neck muscle blockade

Neuromuscular blocking potency is 3 times that of atracurium; maximum block is up to 2 minutes longer than for equipotent doses of atracurium

Injection, as besylate: 2 mg/mL (5 mL, 10 mL); 10 mg/mL (20 mL)

Belmont MR, Lien CA, Quessy S, et al, "The Clinical Neuromuscular Pharmacology of 51W89 in Patients Receiving Nitrous Oxide/Opioid/Barbiturate Anesthesia," Anesthesiology, 1995, 82(5):1139-45.

Konstadt SN, Reich DL, Stanley TE 3d, et al, "A Two Center Comparison of the Cardiovascular Effects of Cisatracurium (Nimbex®) and Vecuronium in Patients with Coronary Artery Disease," Anesth Analg, 1995, 81(5):1010-4.

Lien CA, Belmont MR, Abalos A, et al, "The Cardiovascular Effects and Histamine-Releasing Properties of 51W89 in Patients Receiving Nitrous Oxide/Opioid/Barbiturate Anesthesia," Anesthesiology, 1995, 82(5):1131-8.

Prielipp RC, Coursin DB, Scuderi PE, et al, "Comparison of the Infusion Requirements and Recovery Profiles of Vecuronium and Cisatracurium 51W89 in Intensive Care Unit Patients," Anesth Analg, 1995, 81(1):3-12.

Sorooshian SS, Stafford MA, Eastwood NB, et al, "Pharmacokinetics and Pharmacodynamics of Cisatracurium in Young and Elderly Adult Patients," Anesthesiology, 1996, 84(5):1083-91.