Cisatracurium Intravenous Infusion for Adults

Who can administer

Administration RESTRICTED - see Appendix 1

Important information

• Critical care administration ONLY. 
• Deep sedation (RAAS < -3) is mandatory and should be assessed prior to commencing an neuromuscular blockade (NMBA) ^{(ref 1)}
• All patients on NMBA infusions should be administered regular lubricating eye care and eyelids should remain closed to protect against corneal injury ^{(ref 2)}
• For Y-site compatibility see below

Available preparations

Nimbex  2mg/ml solution for injection/infusion
Cisatracurium Kalceks  2mg/ml solution for injection/infusion

Reconstitution

Already in solution 

Infusion fluids

Sodium chloride 0.9% (preferred) or Glucose 5%

Methods of intravenous administration

Bolus intravenous injection 

• Loading dose only 

Continuous intravenous infusion (using an electronically controlled infusion device)

• Use undiluted

Dose in adults

Intensive Care Unit Paralysis ^{(ref 1)} 

• To facilitate mechanical ventilation
• For shivering from therapeutic hypothermia (unlicensed) ^{(ref 2)}
• Use for up to 48hours in patients with early Acute Respiratory Distress Syndrome (ARDS)  with PaO2/FiO2 <150 (unlicensed) ^{(ref 2)}  

Dose

• Initial bolus dose of 0.15mg/kg, followed immediately by a continuous infusion of 1 to 3 mcg/kg/minute. 
• Adjust rate thereafter accordingly. 
• The infusion rate may range from 0.5 to 10mcg/kg/minute 
• See table 1 below

Table 1: Cisatracurium  loading and maintenance rates using 2mg/ml solution
Weight (kg)	Loading Dose (0.15mg/kg)	Maintenance infusion 1mcg/kg/minute	Maintenance infusion 3mcg/kg/minute
40kg	6mg (3ml)	2.4mg/hr (1.2ml/hr)	7.2mg/hr (3.6ml/hr)
45kg	6.8mg (3.4mL)	2.8mg/hr (1.4ml/hr)	8.2mg/hr (4.1ml/hr)
50kg	7.6mg (3.8ml)	3mg/hr (1.5ml/hr)	9mg/hr (4.5ml/hr)
55kg	8.2mg (4.1ml)	3.4mg/hr (1.7ml/hr)	10mg/hr (5ml ml/hr)
60kg	9mg (4.5ml)	3.6mg/hr (1.8ml/hr)	10.8mg/hr (5.4ml/hr)
65kg	9.8mg (4.9ml)	4mg/hr (2 ml/hr)	11.8mg/hr (5.9ml/hr)
70kg	10.6mg (5.3ml)	4.2mg/hr (2.1ml/hr)	12.6mg/hr (6.3ml/hr)
75kg	11.2mg (5.6ml)	4.6mg/hr (2.3ml/hr)	13.6mg/hr (6.8ml/hr)
80kg	12mg (6ml)	4.8mg/hr (2.4ml/hr)	14.4mg/hr (7.2ml/hr)
To avoid excessive dosage in obese patients, consider dose calculation using ideal body-weight (ref 3) Ideal Body Weight  - MDCalc

Monitoring

• Monitor neuromuscular function during usage to individualise dosage requirements
• Neuromuscular blockade should be reviewed with a view to stop after 48hours if PF ratio >150, regardless of mean airway pressure ^{(ref 5)} 
• Monitor for acid-base and/or serum electrolyte abnormalities that may increase/decrease the sensitivity of a patient to neuromuscular blockade agents

Further information

• Patients with myasthenia gravis and other forms of neuromuscular disease have shown greatly increased sensitivity to non-depolarising blocking agents. A loading dose of not more than 0.02mg/kg is recommended in these patients. 
• Degradation of cisatracurium has been demonstrated to occur more rapidly in glucose 5% than in sodium chloride 0.9% and it is recommended that glucose 5% is not used as the diluent in preparing cisatracurium for infusion ^{(ref 4)}
• NMBAs are hydrophilic compounds with small Vd, suggesting that their distribution into adipose tissue is limited ^{(ref 1)}
   

Storage

• Store in a refrigerator (2-8⁰C)
• SAFETY: Must be segregated from other drugs in fridge to avoid inadvertent drug selection errors ^{(ref 6)}
  • Section in fridge must have adequate warning labels

References

SPC Nimbex. Aug 2021, 
SPC Cisatracurium Kalceks Sept 2019
1. Critical Illness- medicinescomplete.com. Accessed Jan 13th 2022.
2. Cisatracurium: Drug Information. Uptodate. Accessed Jan 13th 2022
3. BNF - medicinescomplete.com. Accessed Jan 11th 2022.
4. AHSP - medicinescomplete.com. Accessed Jan 11th 2022
5. Verbal communication with Prof. Patrick Neligan 23rd Feb 2022
6: ISMP Targeted Medication Safety Best Practices for Hospitals 2020-2021. Accessed Jan 26th 2022

Therapeutic classification

Neuromuscular blocker