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
- Where cisatracurium is used in conjunction with isoflurane or enflurane a REDUCTION in infusion rate of 40% may be required
Available preparations
Cisatracurium JUNO 2mg/ml solution for injection/infusion (unlicensed) (5mg/ml ampoules also exist, check carefully)
Nimbex 2mg/ml solution for injection/infusion
Reconstitution
Already in solution
Infusion fluids
Sodium chloride 0.9% (preferred) or Glucose 5% (less stable, avoid)
Methods of intravenous administration
Bolus intravenous injection
Continuous intravenous infusion (using an electronically controlled infusion device)
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 an initial continuous infusion of 3 mcg/kg/minute
- Adjust rate thereafter accordingly.
- The infusion rate may range from 0.5 to 10mcg/kg/minute (large variation amongst individuals)
- 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 JUNO. 31 March 2023
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
