Cisatracurium

Cisatracurium may be found in some form under the following brand names:

• Nimbex

Cisatracurium is injected into a vein through an IV. A healthcare provider will give you this injection.

Your breathing, blood pressure, oxygen levels, kidney function, and other vital signs will be watched closely while you are receiving cisatracurium. Your blood will also need to be tested daily during treatment, and you may also need chest x-rays.

Since cisatracurium is used during surgery, it does not have a daily dosing schedule.

• Tell all of your health care providers that you take cisatracurium. This includes your doctors, nurses, pharmacists, and dentists.
• Very bad and sometimes deadly allergic side effects have rarely happened. Talk with your doctor.
• Some products have benzyl alcohol. Do not give a product that has benzyl alcohol in it to a newborn. Talk with the doctor to see if this product has benzyl alcohol in it.
• If you are 65 or older, use this medicine with care. You could have more side effects.
• Tell your doctor if you are pregnant or plan on getting pregnant. You will need to talk about the benefits and risks of using cisatracurium while you are pregnant.
• Tell your doctor if you are breast-feeding. You will need to talk about any risks to your baby.

If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.

Dose dependent, 35 to 45 minutes after a single 0.1 mg/kg dose; recovery begins in 20-35 minutes when anesthesia is balanced; recovery is attained in 90% of patients in 25-93 minutes

Half-Life Elimination

22-29 minutes

Protein Binding

Not studied due to rapid degradation at physiologic pH

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 of 25°C (77°F). Per the manufacturer, dilutions of 0.1 mg/mL in 0.9% sodium chloride (NS), dextrose 5% in water (D5W), or D5NS are stable for up to 24 hours at room temperature or under refrigeration; dilutions of 0.1-0.2 mg/mL in D5LR are stable for up to 24 hours in the refrigerator. Additional stability data: Dilutions of 0.1, 2, and 5 mg/mL in D5W or NS are stable in the refrigerator for up to 30 days; at room temperature (23°C), dilutions of 0.1 and 2 mg/mL began exhibiting substantial drug loss between 7-14 days; dilutions of 5 mg/mL in D5W or NS are stable for up to 30 days at room temperature (23°C) (Xu, 1998). Usual concentration: 0.1-0.4 mg/mL.

Concern related to adverse effects:

• Bradycardia: May be more common with cisatracurium than with other neuromuscular-blocking agents since it has no clinically-significant effects on heart rate to counteract the bradycardia produced by anesthetics.

• Neuromuscular cross-sensitivity: Cross-sensitivity with other neuromuscular-blocking agents may occur; use extreme caution in patients with previous anaphylactic reactions to other neuromuscular-blocking agents.

Disease-related concerns:

• Burn injury: Resistance may occur in burn patients (≥20% of total body surface area), usually several days after the injury, and may persist for several months after wound healing (Han, 2009).

• Conditions which may antagonize neuromuscular blockade: Respiratory alkalosis, hypercalcemia, demyelinating lesions, peripheral neuropathies, denervation, and muscle trauma may result in antagonism of neuromuscular blockade (Greenberg, 2013; Miller, 2010; Murray, 2002; Naguib, 2002).

• Conditions which may potentiate neuromuscular blockade: Electrolyte abnormalities (eg, severe hypocalcemia, severe hypokalemia, hypermagnesemia), neuromuscular diseases, metabolic acidosis, metabolic alkalosis, respiratory acidosis, Eaton-Lambert syndrome and myasthenia gravis may result in potentiation of neuromuscular blockade (Greenberg, 2013; Miller, 2010; Naguib, 2002).

• Therapeutic hypothermia: Hypothermia may slow Hoffmann elimination thereby prolonging the duration of activity (Greenberg, 2013).

Special populations:

• Elderly: Use with caution in the elderly, effects and duration are more variable.

• Immobilized patients: Resistance may occur in patients who are immobilized.

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension and cardiovascular collapse (AAP ["Inactive" 1997]; CDC, 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors, 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer’s labeling.

Other warnings/precautions:

• Appropriate use: Maintenance of an adequate airway and respiratory support is critical.

• Experienced personnel: Should be administered by adequately trained individuals familiar with its use.

Peripheral nerve stimulator measuring twitch response (when appropriate); vital signs (heart rate, blood pressure, respiratory rate)

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.