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All about: Cisatracurium Besylate

Big Image 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

Mechanism of Action

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.

Adults

IV 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 Impairment

IV 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 age

IV 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 Infusion
Adults 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 Room
Adults

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, quinidine

May enhance the neuromuscular blocking action of cisatracurium.

Carbamazepine, phenytoin

Resistance to neuromuscular blocking action of cisatracurium may occur.

Nitrous oxide/oxygen with either enflurane or isoflurane

May prolong the clinically effective duration of action of initial and maintenance doses of cisatracurium and decrease the required infusion rate.

Succinylcholine

Time 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

Monitor

Respiratory status

Assess respiratory status frequently. Inform health care provider immediately if deterioration in respiratory status or blood gases are noted.

Vital signs

Monitor 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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