cisatracurium
Brand: Nimbex
ISMP High Alert Prototype: succinylcholine
Drug Class: neuromuscular blocking agent (NMBA)
Drug Family: neuromuscular blocking agent
Subclass: non-depolarizing NMBA (benzylisoquinolinium)
Organ Systems: cnsmusculoskeletal
Mechanism of Action
Intermediate-duration non-depolarizing NMBA that undergoes organ-independent Hofmann elimination at physiological pH and temperature, producing laudanosine and monoquaternary acrylate as inactive metabolites. This unique elimination pathway makes it ideal for patients with organ failure.
nicotinic acetylcholine receptor at NMJ (competitive antagonist)
Indications
- facilitation of endotracheal intubation
- intraoperative skeletal muscle relaxation
- facilitation of mechanical ventilation in ICU (preferred in organ failure)
Contraindications
- hypersensitivity to cisatracurium
Adverse Effects
Common
- bradycardia (minimal histamine release unlike atracurium)
Serious
- laudanosine accumulation (CNS stimulant in theory at very high doses; clinical significance unclear)
- anaphylaxis (rare)
Pharmacokinetics (ADME)
| Absorption | IV only |
| Distribution | protein binding ~<1%; Vd ~0.16 L/kg |
| Metabolism | Hofmann elimination (organ-independent) at physiological pH and temperature; also some ester hydrolysis |
| Excretion | renal and fecal (inactive metabolites) |
| Half-life | 22-31 minutes |
| Onset | 1.5-2 minutes |
| Peak | 3-5 minutes |
| Duration | 45-75 minutes |
| Protein Binding | <1% |
| Vd | 0.16 L/kg |
Drug Interactions
| Drug / Agent | Mechanism | Severity |
|---|---|---|
| aminoglycosides | potentiate neuromuscular blockade | moderate |
Nursing Considerations
- Preferred NMBA in ICU patients with renal and hepatic failure because Hofmann elimination does not depend on organ function.
- Stable in refrigerator; once removed from refrigerator, use within 21 days at room temperature.
- Reverse with neostigmine (with anticholinergic) when TOF count 2 or more; can also be reversed by sugammadex off-label.
- No histamine release at standard doses; less cardiovascular effect than atracurium — preferred in hemodynamically sensitive patients.
Clinical Pearls
- Cisatracurium is the NMBA of choice in critically ill patients with multiorgan failure: organ-independent Hofmann elimination ensures predictable pharmacokinetics regardless of renal or hepatic dysfunction.
- The ACURASYS and ROSE trials evaluated cisatracurium infusion in ARDS; the evidence for routine use is now considered insufficient, but it remains used for specific indications like facilitation of prone positioning.
Safety Profile
Pregnancy use-with-caution
Lactation use-with-caution
Renal Adjustment Not required
Hepatic Adjustment Not required
TDM Not required
Concordance Terms
Cross-referenced clinical concepts — click any term to see all content where it appears.