Cisatracurium

NIMBEX

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Pronunciation: sis-at-ra-KYOOR-ee-um

Cisatracurium ballicule: receptor binding, kinetics and half-life diagram — Mechanism of action: Cisatracurium ballicule

What it isNondepolarizing muscle nicotinic-receptor antagonist cleared by Hofmann elimination; surgical and ICU paralysis.

Why this oneOrgan-independent clearance with little histamine release makes it especially useful in critically ill patients.

What limits itIts slow onset makes it unsuitable for rapid-sequence intubation. Paralysis provides no sedation or analgesia.

Cisatracurium molecular structure (skeletal formula) — Molecular structure: Cisatracurium

FDA-approved for

neuromuscular blockade (surgery) (1995)

FDA label

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FDA dosing	Population	Start	Target	Max
Tracheal intubation	Adult		0.15-0.2 mg/kg IV bolus	0.4 mg/kg (studied)
Maintenance neuromuscular blockade	Adult		0.03 mg/kg IV bolus
Neuromuscular disease (intubation)	Adult		max initial bolus 0.02 mg/kg	0.02 mg/kg
Continuous infusion (surgical)	Adult/peds ≥2 y	3 mcg/kg/min	1-2 mcg/kg/min
ICU mechanical ventilation	Adult	3 mcg/kg/min	0.5-10.2 mcg/kg/min
Tracheal intubation	Infant 1-23 mo		0.15 mg/kg IV
Tracheal intubation	Child 2-12 y		0.1-0.15 mg/kg IV

Renal No adjustment needed (recovery profile unchanged; time to blockade ~1 min slower in end-stage renal disease)

Hepatic No adjustment needed (minor PK differences; no clinically significant change in recovery)

First maintenance bolus 40-50 min after 0.15 mg/kg initial dose (50-60 min after 0.2 mg/kg).

Instructions

IV use only; administer by/under supervision of experienced clinicians with resuscitation available
Use a peripheral nerve stimulator to monitor depth of blockade and guide dosing
Reduce infusion rate ~30-40% during stable isoflurane/inhalational anesthesia; halve rate for CABG with induced hypothermia
Consider increased doses in burn patients (resistance to nondepolarizing blockers)

Available strengths

inj 2, 10 mg/mL

Cautions

Residual paralysis (higher risk in neuromuscular disease); extubate only after adequate recovery
Seizure risk from laudanosine metabolite with prolonged use in renal/hepatic impairment
Severe hypersensitivity/anaphylaxis; cross-reactivity among neuromuscular blockers
Risk of death from medication errors (accidental administration)
Requires adequate sedation/anesthesia (awareness while paralyzed)
Neuromuscular blockade potentiated by certain drugs and electrolyte/acid-base abnormalities
Malignant hyperthermia (not studied)

Adverse reactions

Bradycardia
Hypotension
Flushing
Bronchospasm
Rash

Pregnancy No human data; no maternal or fetal toxicity in animals. 10 mL multiple-dose vial contains benzyl alcohol — use a benzyl alcohol-free formulation in pregnancy.

Lactation No data on presence in human milk; 10 mL multiple-dose vial contains benzyl alcohol — consider a benzyl alcohol-free formulation.

Cost

Cisatracurium (NIMBEX)

Strength		#/mo	generic $/unit	CostPlus
2 mg/mL	inj	per unit		not offered
10 mg/mL	inj	per unit		not offered

NADAC is a voluntary CMS survey of what retail community pharmacies pay for the drugs they stock. Cisatracurium is administered under clinical supervision and dispensed outside retail pharmacies, so it rarely appears on surveyed invoices.

NO BOXED WARNINGS

Principal riskNo sedation whatever; slow onset

Classes and tags

Clinical profile

Therapeutic safety burden3 / 4

Sedation liability0 / 4

Direct muscarinic antagonism0 / 4

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