Massachusetts General Hospital

Department of Pharmacy

Department of Nursing

Critical Care Guidelines
Generic Name: Cisatracurium
Trade Name: Nimbex
Actions: Non-Depolarizing Skeletal Muscle Relaxant
Indications: - Provide skeletal muscle relaxation during surgeryand during mechanical ventilation in the ICU

- Adjunct to general anesthesia


- Facilitate tracheal intubation
Administration Guidelines:
For continuous infusion:

 

 Usual Dose and Route:
Initial: Bolus of 10mg to 15mg over 5 to 10 seconds

Maintenance: 4mg to 12mg/ hour. Dose may vary according to responce.
Standard Concentration: 10mg/100ml, 250mg/250ml, 250mg/500ml

Microinfusion:

100mg/50ml syringe
Special Considerations: -Paralytic therapy should be started only after adequate sedation therapy has been initiated.

-Ongoing sedation should be maintained and evaluated periodically.

-Neuromuscular function should be monitored with a peripheral nerve-stimulator during administration and dose adjusted accordingly.

-Adequate level of paralysis is generally considered to be 1-2 out of 4 on the train of four with a peripheral nerve stimulator

- Cisatracurium has no effect on pain threshold.
-Not recommended for rapid sequence endotracheal intubation due to intermediate
onset of action.
-Organ independent: Hoffman elimination is the predominant pathway for elimination*
-Slower time to onset in elderly and patients with renal dysfunction.
-Reduce dose in patients with neuromuscular disease (e.g. myasthenia gravis).
-Acid-base and/or serum electrolyte abnormalities may potentiate or antagonize the action (increase pH, decrease T1/2; decreased pH, increase T1/2).
-Burn patients and patients with hemiparisis/paraparesis may develop resistance
-Store vials in refrigerator
-Vials warmed to room temperature should be used within 21 days even if re-refrigerated thereafter.

Precautions/Side Effects: Adverse reactions uncommon; less than 1% incidence of: bradycardia,
hypotension, flushing, bronchospasm, rash, metabolite accumulation, as shown
in animal studies, may contribute to transient hypotension and possible increase
seizure risk, esp. with long term use, due to accumulation of metabolite
landonosine.

*Liver and kidney are primary pathways for the elimination of metabolites. Metabolite concentrations may be higher in ICU patients with renal or hepatic failure.

revised 09/03