Induction of skeletal muscle paralysis and facilitation of intubation after induction of anesthesia in surgical procedures.
Facilitation of compliance during mechanical ventilation.
Action
Prevents neuromuscular transmission by blocking the effect of acetylcholine at the myoneural junction. Has no analgesic or anxiolytic properties
Therapeutic Effect(s):
Skeletal muscle paralysis
Pharmacokinetics
Absorption: Following IV administration, absorption is essentially complete.
Distribution: Rapidly distributes into extracellular fluid;
Metabolism and Excretion: Undergoes pH-dependent breakdown, which is responsible for 80% of metabolism; remainder eliminated by liver and kidneys.
Half-life: 22–31 min;
TIME/ACTION PROFILE
ROUTE
ONSET
PEAK
DURATION
IV
2–3min
3–5 min
28–50 min
Contraindication/Precautions
Contraindicated in:
Hypersensitivity
Pedi: Products containing benzyl alcohol should be avoided in neonates.
Use Cautiously in:
Dehydration or electrolyte abnormalities (should be corrected)
Fractures or muscle spasm
Hyperthermia (↑ duration/intensity of paralysis)
Shock
Extensive burns (may be more resistant to effects)
Low plasma pseudocholinesterase levels (may be seen in association with anemia, dehydration, cholinesterase inhibitors/insecticides, severe liver disease, pregnancy, or hereditary predisposition)
Obese patients
OB: Lactation: Safety not established (use only if benefit outweighs potential risk to fetus)
Pedi: Children <1 mo (safety and effectiveness not established)
Exercise Extreme Caution in:
Neuromuscular diseases such as myasthenia gravis (small test dose may be used to assess response).
Adverse Reactions/Side Effects
Resp: bronchospasm
Derm: rash
Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS
* CAPITALS indicate life-threatening. Underline indicate most frequent.
Interactions
Drug-Drug
Intensity and duration of paralysis may be prolonged by pretreatment with succinylcholine, general anesthesia (inhalation), aminoglycosides, vancomycin, tetracyclines, polymyxin B, colistin, clindamycin, lidocaine, and other local anesthetics, lithium, quinidine, procainamide, beta-adrenergic blocking agents, potassium-losing diuretics, or magnesium.
Higher infusion rates may be required and duration of action may be shortened in patients receiving long-term carbamazepine or phenytoin.
Route/Dosage
IV (Adults and Children >12 yr): Initial intubating dose– 0.15–0.2 mg/kg, additional maintenance doses of 0.03 mg/kg may be used 40–65 min later; Continuous infusion– 1–3 mcg/kg/min.
IV (Infants 1–23 mo): Initial intubating dose– 0.15 mg/kg.
Availability (generic available)
Solution for injection: 2 mg/mL, 10 mg/mL
Assessment
Assess respiratory status continuously throughout therapy with cisatracurium. Use only to facilitate intubation or in patients already intubated.
Monitor neuromuscular response with a peripheral nerve stimulator intraoperatively. Paralysis is initially selective and usually occurs sequentially in the following muscles: levator muscles of eyelids, muscles of mastication, limb muscles, abdominal muscles, muscles of the glottis, intercostal muscles, and the diaphragm. Recovery of muscle function usually occurs in reverse order.
Monitor ECG, heart rate, and BP throughout administration.
Observe the patient for residual muscle weakness and respiratory distress during the recovery period.
Monitor infusion site frequently. If signs of tissue irritation or extravasation occur, discontinue and restart in another vein.
Toxicity Overdose:
If overdose occurs, use peripheral nerve stimulator to determine the degree of neuromuscular blockade. Maintain airway patency and ventilation until recovery of normal respirations occurs.
Administration of anticholinesterase agents (neostigmine, pyridostigmine) may be used to antagonize the action of cisatracurium once the patient has demonstrated some spontaneous recovery from neuromuscular block. Atropine is usually administered prior to or concurrently with anticholinesterase agents to counteract the muscarinic effects.
Administration of fluids and vasopressors may be necessary to treat severe hypotension or shock.
High Alert: Unplanned administration of a neuromuscular blocking agent instead of administration of the intended medication or administration of a neuromuscular blocking agent in the absence of ventilatory support has resulted in serious harm and death. Confusing similarities in packaging and insufficiently controlled access to these medications are often implicated in these medication errors.
Dose is titrated to patient response.
Cistracurium has no effect on consciousness or pain threshold. Adequate anesthesia/analgesia should always be used when neuromuscular blocking agents are used as an adjunct to surgical procedures or when painful procedures are performed. Benzodiazepines and/or analgesics should be administered concurrently when prolonged neuromuscular blocker therapy is used for ventilator patients, because patient is awake and able to feel all sensations.
Not recommended for rapid sequence endotracheal intubation due to intermediate onset of action.
If eyes remain open throughout prolonged administration, protect corneas with artificial tears.
IV Administration
IV Push: May be administered undiluted.
Rate: Administer initial IV dose as a bolus over 1 min.
Intermittent Infusion:
Maintenance dose is usually required 40–60min following initial dose.
Diluent: D5W, 0.9% NaCl, D5/0.9% NaCl., or D5/LR. Solutions diluted to 0.1 mg/mL in D5/W, 0.9% NaCl, or D5/0.9% NaCl may be stored at room temperature or in refrigeration for 24 hrs. Solutions dilutes 0.1–0.2 mg/mL in D5/LR may be stored for up to 24 hrs in refrigerator.
Continuous Infusion: Maintenance dose is administered by infusion. .
Rate: 3 mcg/kg/min intially, then 1–2 mcg/kg/min. Titrate according to patient response.
Y-Site Compatibility
alemtuzumab
alfentanil
amikacin
aminocaproic acid
amiodarone
amphotericin B lipid complex
anidulafungin
argatroban
arsenic trioxide
azithromycin
aztreonam
bivalirudin
bleomycin
bumetanide
buprenorphine
butorphanol
calcium gluconate
carboplatin
carmustine
caspofungin
ceftaroline
cefotaxime
ceftriaxone
chlorpromazine
ciprofloxacin
cisplatin
clindamycin
cyclophosphamide
cytarabine
dactinomycin
daptomycin
dexamethasone
dexmedetomidine
dexrazoxane
digoxin
diltiazem
diphenhydramine
dobutamine
docetaxel
dopamine
doxorubicin hydrochloride liposome
doxycycline
enalaprilat
epinephrine
epirubicin
eptifibatide
ertapenem
esmolol
etoposide
etoposide phosphate
famotidine
fenoldopam
fentanyl
fluconazole
fludarabine
fluorouracil
foscarnet
gemcitabine
gentamicin
granisetron
haloperidol
hetastarch
hydrocortisone sodium succinate
hydromorphone
idarubicin
ifosfamide
imipenem/cilastatin
irinotecan
isoproterenol
ketorolac
leucovorin
levofloxacin
lidocaine
linezolid
lorazepam
magnesium sulfate
mannitol
meperidine
methotrexate
metoclopramide
metronidazole
midazolam
milrinone
minocycline
mitoxantrone
morphine
mycophenolate
nafcillin
nalbuphine
nicardipine
nitroglycerin
norepinephrine
octreotide
ondansetron
oxaliplatin
oxytocin
paclitaxel
palonosetron
pamidronate
papaverine
pemetrexed
phenylephrine
potassium acetate
potassium chloride
procainamide
prochlorperazine
promethazine
quinupristin/dalfopristin
ranitidine
remifentanil
sodium acetate
sufentanil
tacrolimus
teniposide
theophylline
thiotepa
tigecycline
tirofiban
tobramycin
tolazoline
vancomycin
vasopressin
vinblastine
vincristine
vinorelbine
voriconazole
zidovudine
zoledronic acid
Y-Site Incompatibility
amphotericin B cholesteryl
micafungin
pantoprazole
Patient/Family Teaching
Explain all procedures to patient receiving cisatracurium therapy without general anesthesia, because consciousness is not affected by cisatracurium alone.
Reassure patient that communication abilities will return as the medication wears off.
Evaluation/Desired Outcomes
Adequate suppression of the twitch response when tested with peripheral nerve stimulation and subsequent muscle paralysis.
Improved compliance during mechanical ventilation.
cisatracurium is a sample topic from the Davis's Drug Guide.
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