CISATRACURIUM BESYLATE

CISATRACURIUM BESYLATE
(cis-a-tra-kyoo-ri'um)
Nimbex
Classifications: skeletal muscle relaxant, nondepolarizing; neuromuscular blocker;
Therapeutic: skeletal muscle relaxant

Prototype: Atracurium
Pregnancy Category: B

Availability

2 mg/mL, 10 mg/mL injection

Action

Cisatracurium is a neuromuscular blocking agent with intermediate onset and duration of action compared with similar agents. It binds competitively to cholinergic receptors on the motor endplate of neurons, antagonizing the action of acetylcholine.

Therapeutic Effect

Antagonism of acetylcholine blocks neuromuscular transmission of nerve impulses. This action can be reversed or antagonized by acetylcholinesterase inhibitors (e.g., neostigmine).

Uses

Adjunct to general anesthesia to facilitate tracheal intubation and provide skeletal muscle relaxation during surgery or mechanical ventilation.

Contraindications

Hypersensitivity to cisatracurium or other related agents; rapid-sequence endotracheal intubation. Not studied in infants <1 mo.

Cautious Use

History of hemiparesis, electrolyte imbalances, burn patients, pulmonary disease, COPD; neuromuscular diseases (e.g., myasthenia gravis), older adults, renal function impairment, pregnancy (category B), lactation.

Route & Dosage

Intubation
Adult: IV 0.15 or 0.20 mg/kg
Child (2–12 y): IV 0.1–0.15 mg/kg
Infant (>1 mo): IV 0.15 mg/kg

Maintenance
Adult: IV 0.03 mg/kg q20min prn or 1–2 mcg/kg/min
Child (≥2 y) : IV 1–2 mcg/kg/min

Mechanical Ventilation in ICU
Adult: IV 3 mcg/kg/min (can range from 0.5 to 10.2 mcg/kg/min)

Administration

  • Administer carefully adjusted, individualized doses using a peripheral nerve stimulator to evaluate neuromuscular function.
  • Give only by or under supervision of expert clinician familiar with the drug's actions and potential complications.
  • Have immediately available personnel and facilities for resuscitation and life support and an antagonist of cisatracurium.
  • Refer to manufacturer's guidelines for preparation and administration. Note that 10-mL multiple-dose vials contain benzyl alcohol and should not be used with neonates.
Intravenous

PREPARE: Direct: Give undiluted.  IV Infusion: Dilute 10 mg in 95 mL or 40 mg in 80 mL of compatible IV fluid to prepare 0.1 mg/mL or 0.4 mg/mL, respectively, IV solution. Compatible IV fluids include D5W, NS, D5/NS, D5/RL.  ICU IV Infusion: Dilute the contents of the 200 mg vial (i.e., 10 mg/mL) in 1000 mL or 500 mL of compatible IV fluid to prepare 0.2 mg/mL or 0.4 g/mL, respectively, IV solutions.  

ADMINISTER: Direct: Give a single dose over 5–10 sec.  IV Infusion: Adjust the rate based on patient's weight.  

INCOMPATIBILITIES Solution/additive: Ketorolac, propofol (dose dependent). Y-site: Amphotericin B, amphotericin B cholesteryl complex, ampicillin, cefazolin, cefotaxime, cefotetan, cefuroxime, diazepam, furosemide, ganciclovir, heparin, methylprednisolone, sodium bicarbonate, thiopental, trimethoprim/sulfamethoxazole.

  • Refrigerate vials at 2°–8° C (36°–46° F). Protect from light. Diluted solutions may be stored refrigerated or at room temperature for 24 h.

Adverse Effects (≥1%)

CV: Bradycardia, hypotension, flushing. Respiratory: Bronchospasm. Skin: Rash.

Pharmacokinetics

Onset: Varies from 1.5 to 3.3 min (higher dose has faster onset). Peak: Varies from 1.5 to 3.3 min (higher dose has faster peak). Duration: Varies with dose from 46 to 121 min (higher dose, longer recovery time). Metabolism: Undergoes Hoffman elimination (pH- and temperature-dependent degradation) and hydrolysis by plasma esterases. Elimination: In urine. Half-Life: 22 min.

Nursing Implications

Assessment & Drug Effects

  • Perform neuromuscular monitoring only on nonparetic limbs.
  • Time-to-maximum neuromuscular block is 1 min slower in the older adult.
  • Monitor for bradycardia, hypotension, and bronchospasms; monitor ICU patients for spontaneous seizures.
  • Antagonists should not be given when complete neuromuscular block is present.

Common adverse effects in italic, life-threatening effects underlined; generic names in bold; classifications in SMALL CAPS; Canadian drug name; Prototype drug

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