Cisatracurium: Pediatric drug information

For additional information see "Cisatracurium: Drug information" and "Cisatracurium: Patient drug information"

For abbreviations, symbols, and age group definitions show table

Brand Names: US

Nimbex [DSC]

Brand Names: Canada

Cisatracurium Omega

Therapeutic Category

Neuromuscular Blocker Agent, Nondepolarizing;
Skeletal Muscle Relaxant, Paralytic

Dosing: Neonatal

Neuromuscular blockade

Neuromuscular blockade: Very limited data available: Continuous IV infusion: Initial: 1 mcg/kg/minute (0.06 mg/kg/hour); titrate until desired neuromuscular blockade is achieved; rates were adjusted in 25% to 100% increments; dosing based on a prospective randomized trial which compared cisatracurium and vecuronium in neonates, infants, and children <2 years of age requiring mechanical ventilation following congenital heart surgery (n=19; cisatracurium group n=10; age range: 3 to 33 days; weight range: 2.7 to 6 kg); the average infusion rate of cisatracurium was 2.8 mcg/kg/minute (0.168 mg/kg/hour) and ranged from 0.6 to 4.9 mcg/kg/minute (0.036 to 0.294 mg/kg/hour); the final infusion doses ranged from 0.75 to 11.5 mcg/kg/minute (0.045 to 0.69 mg/kg/hour); patients receiving cisatracurium had a significantly faster neuromuscular recovery time following discontinuation compared to patients receiving vecuronium (30 vs 180 minutes); however, no differences in duration of mechanical ventilation, need for reintubation, or duration of ICU or hospital stay were noted between the groups (Ref).

Dosing: Pediatric

Note: Dosing in obese patients should be calculated using ideal body weight (Ref):

Neuromuscular blockade

Neuromuscular blockade:

Intermittent dosing:

Infants and Children <2 years: IV: 0.15 mg/kg/dose over 5 to 10 seconds.

Children ≥2 years and Adolescents: IV: 0.1 to 0.15 mg/kg/dose over 5 to 10 seconds (Ref).

Continuous IV infusion: Infants, Children, and Adolescents: 1 to 4 mcg/kg/minute (0.06 to 0.24 mg/kg/hour); 3.9 ± 1.3 mcg/kg/minute (0.23 ± 0.08 mg/kg/hour) was the mean infusion rate needed to maintain neuromuscular blockade in 19 children (ages 3 months to 16 years) (Ref); higher doses have been reported with prolonged infusions (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling. Slower times to onset of complete neuromuscular block were observed in renal dysfunction patients; extending the interval between the administration of cisatracurium and intubation attempt may be required to achieve adequate intubation conditions.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling. The time to onset of action was ~1 minute faster in liver transplant patients but was not associated with clinically significant changes in recovery time.

Dosing: Adult

(For additional information see "Cisatracurium: Drug information")

Dosage guidance :

Dosing: Doses must be individualized due to interpatient variability, patient-specific factors, and/or comorbidities (eg, severe trauma, burn injury) (Ref).

Endotracheal intubation

Note: Ensure adequate pain control and sedation prior to and during administration of neuromuscular blockade.

Endotracheal intubation: IV: 0.15 to 0.2 mg/kg once.

Rapid sequence intubation, neuromuscular blockade (alternative agent) (off-label use):

Note: Experts only consider use when succinylcholine or rocuronium is contraindicated or not available; may have a delayed onset of action when compared to succinylcholine or rocuronium (Ref).

IV: 0.4 mg/kg once (Ref).

Mechanically ventilated patients in the ICU, neuromuscular blockade

Mechanically ventilated patients in the ICU, neuromuscular blockade: Note: Ensure adequate pain control and sedation prior to and during administration of neuromuscular blockade. May use to facilitate mechanical ventilation (eg, refractory moderate to severe acute respiratory distress syndrome; refractory, life-threatening status asthmaticus; shivering from therapeutic hypothermia) (Ref). Refer to institutional protocols; titration specifics may vary.

Continuous infusion: IV: 0.1 to 0.2 mg/kg initial loading dose, followed by continuous infusion of 1 to 3 mcg/kg/minute; titrate based on clinical response and neuromuscular monitoring (eg, train-of-four); usual dosage range: 0.5 to 10 mcg/kg/minute (Ref).

Neuromuscular blockade during general anesthesia

Neuromuscular blockade during general anesthesia (adjunctive therapy):

Maintenance dosing: Note: Inhaled anesthetic agents (eg, desflurane, isoflurane, sevoflurane) prolong the duration of action of cisatracurium and may potentiate the neuromuscular blockade.

Intermittent dose: IV: 0.01 to 0.03 mg/kg, may repeat as needed based on clinical response and neuromuscular monitoring (eg, train-of-four) (Ref).

Continuous infusion: IV: 1 to 3 mcg/kg/minute as an initial continuous infusion; titrate as needed based on clinical response and neuromuscular monitoring (eg, train-of-four) (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

There are no specific dosage adjustments provided in the manufacturer's labeling. The half-life values of the metabolites are longer in patients with renal failure and concentrations may be higher after long-term administration. In patients with ESRD, consider extending the interval between the administration of cisatracurium and intubation attempt by at least 1 minute to achieve adequate intubation conditions (time to maximum neuromuscular blockade is ~1 minute slower in patients with ESRD).

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer’s labeling. The half-life values of the metabolites are longer in patients with hepatic disease and concentrations may be higher after long-term administration.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Effects are minimal and transient.

<1%, postmarketing, and/or case reports: Bradycardia, bronchospasm, flushing, hypotension, muscle calcification (prolonged use), myopathy (acute quadriplegic syndrome; prolonged use), pruritus, skin rash

Contraindications

Hypersensitivity to cisatracurium or any component of the formulation; use of the 10 mL multiple-dose vials in neonates <1 month of age and low birth-weight infants (formulation contains benzyl alcohol).

Warnings/Precautions

Concern related to adverse effects:

• Anaphylaxis: Severe anaphylactic reactions have been reported (some life-threatening and fatal). Appropriate emergency treatment (including epinephrine 1 mg/mL) should be immediately available during use. Use caution in patients with previous anaphylactic reactions to other neuromuscular blocking agents.

• Bradycardia: May be more common with cisatracurium than with other neuromuscular-blocking agents since it has no clinically-significant effects on heart rate to counteract the bradycardia produced by anesthetics.

• Residual paralysis: Has been reported. Patients with neuromuscular diseases (eg, myasthenia gravis, myasthenic syndrome) and carcinomatosis may be at increased risk; a lower maximum initial bolus dose is recommended in these patients. Reversal agents may be considered, especially in cases where residual paralysis is more likely to occur. To prevent complications from residual paralysis, extubation is recommended only after the patient has sufficiently recovered from neuromuscular blockade.

Disease-related concerns:

• Burn injury: Resistance may occur in burn patients (≥20% of total body surface area), usually several days after the injury, and may persist for several months after wound healing (Han 2009).

• Conditions that may antagonize neuromuscular blockade (decreased paralysis): Respiratory alkalosis, hypercalcemia, demyelinating lesions, peripheral neuropathies, denervation, and muscle trauma may result in antagonism of neuromuscular blockade (ACCM/SCCM/ASHP [Murray 2002]; Greenberg 2013; Miller 2010; Naguib 2002).

• Conditions that may potentiate neuromuscular blockade (increased paralysis): Electrolyte abnormalities (eg, severe hypocalcemia, severe hypokalemia, hypermagnesemia), neuromuscular diseases, metabolic acidosis, respiratory acidosis, Eaton-Lambert syndrome and myasthenia gravis may result in potentiation of neuromuscular blockade (Greenberg 2013; Miller 2010; Naguib 2002).

• Therapeutic hypothermia: Hypothermia may slow Hoffmann elimination thereby prolonging the duration of paralysis (Greenberg 2013).

Special populations:

• Older adult: Use with caution in the elderly, effects and duration are more variable.

• Immobilized patients: Resistance may occur in patients who are immobilized.

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension and cardiovascular collapse (AAP ["Inactive" 1997]; CDC, 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer's labeling.

Other warnings/precautions:

• Appropriate use: Maintenance of an adequate airway and respiratory support is critical. All patients should receive eye care including liberal use of lubricating drops, gel, or ointment and eyelids should remain closed during continuous neuromuscular blockade to protect against damage to the cornea (ulceration and drying).

• Experienced personnel: Should be administered by adequately trained individuals familiar with its use.

• Risk of medication errors: Accidental administration may be fatal. Confirm proper selection of intended product, store vial so the cap and ferrule are intact and the possibility of selecting the wrong product is minimized, and ensure that the intended dose is clearly labeled and communicated, when applicable.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Intravenous, as besylate:

Nimbex: 20 mg/10 mL (10 mL [DSC]) [contains benzyl alcohol]

Generic: 10 mg/5 mL (5 mL); 20 mg/10 mL (10 mL); 200 mg/20 mL (20 mL)

Solution, Intravenous, as besylate [preservative free]:

Nimbex: 10 mg/5 mL (5 mL [DSC]); 200 mg/20 mL (20 mL [DSC])

Generic: 10 mg/5 mL (5 mL); 200 mg/20 mL (20 mL)

Generic Equivalent Available: US

Yes

Pricing: US

Solution (Cisatracurium Besylate (PF) Intravenous)

10 mg/5 mL (per mL): $1.43 - $3.61

200 mg/20 mL (per mL): $5.64 - $17.08

Solution (Cisatracurium Besylate Intravenous)

20 mg/10 mL (per mL): $1.20 - $3.16

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous, as besylate:

Generic: 20 mg/10 mL (10 mL)

Administration: Pediatric

Parenteral: Administer IV only; not for IM injection due to tissue irritation.

Rapid IV injection: Administer undiluted over 5 to 10 seconds.

Continuous IV infusion: Administer via infusion pump.

Administration: Adult

IV: Administer IV only; do not administer IM (excessive tissue irritation). Administer undiluted as bolus injection over 5 to 10 seconds. Continuous infusion administration requires the use of an infusion pump. Do not administer with alkaline solutions simultaneously in the same IV line.

Storage/Stability

Refrigerate intact vials at 2°C to 8°C (36°F to 46°F). Use vials within 21 days upon removal from the refrigerator to room temperature of 25°C (77°F). Per the manufacturer, dilutions of 0.1 mg/mL in 0.9% sodium chloride (NS), dextrose 5% in water (D₅W), or D₅NS are stable for up to 24 hours at room temperature or under refrigeration; dilutions of 0.1 or 0.2 mg/mL in D₅LR are stable for up to 24 hours in the refrigerator. Additional stability data: Dilutions of 0.1, 2, and 5 mg/mL in D₅W or NS are stable in the refrigerator for up to 30 days; at room temperature (23°C), dilutions of 0.1 and 2 mg/mL began exhibiting substantial drug loss between 7-14 days; dilutions of 5 mg/mL in D₅W or NS are stable for up to 30 days at room temperature (23°C) (Xu 1998). Usual concentration: 0.1 to 0.4 mg/mL.

According to the 2020-2021 ISMP Targeted Medication Safety Best Practices for Hospitals, neuromuscular blockers should be segregated, sequestered, and differentiated from all other medication wherever they are stored (ISMP 2020).

Use

Adjunct to general anesthesia, to facilitate endotracheal intubation (FDA approved in ages 1 month to 12 years and adults), provide skeletal muscle relaxation during surgical procedures (FDA approved in ages ≥2 years and adults), and provide skeletal muscle relaxation during mechanical ventilation (FDA approved in adults).

Medication Safety Issues

Sound-alike/look-alike issues:

Nimbex may be confused with NovoLOG

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes (neuromuscular blocker agent) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Acute Care Settings).

Other safety concerns:

Only storing in places within the hospital that they are routinely used.

Placing in sealed boxes or in rapid sequence intubation kits (preferred).

Limiting availability in automated dispensing cabinets to perioperative, labor and delivery, critical care, and emergency departments only.

Placing in separate lidded containers within the pharmacy refrigerator or other isolated pharmacy storage area.

Affixing an auxiliary label to clearly communicate respiratory paralysis will occur and ventilation required on all storage bins and/or automated dispensing pockets/drawers (exception anesthesia-prepared syringes) stating one of the following:

Warning: Causes Respiratory Arrest – Patient Must Be Ventilated

Warning: Paralyzing Agent – Causes Respiratory Arrest

Warning: Causes Respiratory Paralysis – Patient Must Be Ventilated

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program

Acetylcholinesterase Inhibitors: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy

Aminoglycosides: May enhance the therapeutic effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Bacitracin (Systemic): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Botulinum Toxin-Containing Products: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Bromperidol: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Calcium Channel Blockers: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy

Capreomycin: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

CarBAMazepine: May decrease the serum concentration of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy

Cardiac Glycosides: Neuromuscular-Blocking Agents may enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy

Clindamycin (Topical): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Colistimethate: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Management: If possible, avoid concomitant use of these products. Monitor for deeper, prolonged neuromuscular-blocking effects (respiratory paralysis) in patients receiving concomitant neuromuscular-blocking agents and colistimethate. Risk D: Consider therapy modification

Corticosteroids (Systemic): Neuromuscular-Blocking Agents (Nondepolarizing) may enhance the adverse neuromuscular effect of Corticosteroids (Systemic). Increased muscle weakness, possibly progressing to polyneuropathies and myopathies, may occur. Management: If concomitant therapy is required, use the lowest dose for the shortest duration to limit the risk of myopathy or neuropathy. Monitor for new onset or worsening muscle weakness, reduction or loss of deep tendon reflexes, and peripheral sensory decriments Risk D: Consider therapy modification

CycloSPORINE (Systemic): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Fosphenytoin-Phenytoin: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Specifically, this effect is observed with chronic phenytoin administration. Fosphenytoin-Phenytoin may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Specifically, this effects is observed with acute/short term phenytoin administration. Risk C: Monitor therapy

Inhalational Anesthetics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Management: When initiating a non-depolarizing neuromuscular blocking agent (NMBA) in a patient receiving an inhalational anesthetic, initial NMBA doses should be reduced 15% to 25% and doses of continuous infusions should be reduced 30% to 60%. Risk D: Consider therapy modification

Ketorolac (Nasal): May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents (Nondepolarizing). Specifically, episodes of apnea have been reported in patients using this combination. Risk C: Monitor therapy

Ketorolac (Systemic): May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents (Nondepolarizing). Specifically, episodes of apnea have been reported in patients using this combination. Risk C: Monitor therapy

Lincosamide Antibiotics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Lithium: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Local Anesthetics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Loop Diuretics: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Loop Diuretics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Magnesium Salts: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Minocycline (Systemic): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Pholcodine: May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents. Specifically, anaphylaxis has been reported. Risk C: Monitor therapy

Polymyxin B: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Management: If possible, avoid concomitant use of neuromuscular-blocking agents and polymyxin B. If concomitant use cannot be avoided, monitor for deeper, prolonged neuromuscular-blocking effects (eg, respiratory paralysis) in patients receiving this combination. Risk D: Consider therapy modification

Procainamide: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

QuiNIDine: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

QuiNINE: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk X: Avoid combination

Tetracyclines: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Thiazide and Thiazide-Like Diuretics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy

Trimebutine: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy

Vancomycin: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Pregnancy Considerations

Following administration of atracurium, laudanosine, an active metabolite of atracurium and cisatracurium, crosses the placenta (Atherton 1999; Fodale 2002).

Recommendations for using cisatracurium for sustained neuromuscular blockade in pregnant critically ill patients are not available due to insufficient evidence (SCCM [Murray 2016]).

Use with caution in patients treated for preeclampsia/eclampsia; the action of cisatracurium may be enhanced by concomitant medications (consult drug interactions database). Preparations may contain benzyl alcohol; avoid in pregnant patients due to association with gasping syndrome in premature infants.

Monitoring Parameters

Muscle twitch response to peripheral nerve stimulation, heart rate, blood pressure, assisted ventilation status.

Mechanism of Action

Blocks neural transmission at the myoneural junction by binding with cholinergic receptor sites

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: IV: 2 to 3 minutes (dose dependent).

Peak effect: 3 to 5 minutes.

Duration: Dose dependent, 35 to 45 minutes after a single 0.1 mg/kg dose; recovery begins in 20 to 35 minutes when anesthesia is balanced; recovery is attained in 90% of patients in 25 to 93 minutes; hypothermia may prolong the duration of action (NCS [Madden 2017]).

Distribution: V_dss: 145 mL/kg (21% larger V_dss when receiving inhalational anesthetics).

Protein binding: Not studied due to rapid degradation at physiologic pH.

Metabolism: Undergoes rapid nonenzymatic degradation in the bloodstream (Hofmann elimination) to laudanosine and inactive metabolites; laudanosine may cause CNS stimulation (association not established in humans) and has less accumulation with prolonged use than atracurium due to lower requirements for clinical effect.

Half-life elimination: 22 to 29 minutes.

Excretion: Urine (95%; <10% as unchanged drug); feces (4%).

Clearance: Children: 5.89 mL/kg/minute; Adults: 4.57 mL/kg/minute.

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Altered kidney function: The times to 90% block were approximately 1 minute slower in patients with ESRD. The half-life values of the metabolites are longer in patients with renal failure and concentrations may be higher after long-term administration.

Hepatic function impairment: The times to maximum block were approximately 1 minute faster in liver transplant recipients compared with healthy adults. The half-life values of the metabolites are longer in patients with hepatic disease and concentrations may be higher after long-term administration.

Pediatric: Minor differences in pharmacokinetic/pharmacodynamic parameters in children resulted in a faster time to onset and a shorter duration of neuromuscular block.

Older adult: The times to maximum block were approximately 1 minute slower in elderly patients.

Brand Names: International

International Brand Names by Country

For country code abbreviations (show table)

(AE) United Arab Emirates: Nimbex | Sisacure;
(AR) Argentina: Nimbium;
(AT) Austria: Cisatracurium accord | Cisatracurium hikma | Cisatracurium hospira | Cisatracurium kalceks | Nimbex;
(AU) Australia: Cisatracurium aft | Cisatracurium juno | Cisatracurium myx | Cisatracurium sxp | Dbl cisatracurium | Nimbex;
(BD) Bangladesh: Nimbex;
(BE) Belgium: Cisatracurium | Cisatracurium actavis | Cisatracurium Fresenius Kabi | Cisatracurium hospira | Cisatracurium sandoz | Nimbex;
(BF) Burkina Faso: Nimbex;
(BR) Brazil: Bedeci | Bes cisatracuri | Besilato de cisatracurio | Cis | Cisauni | Nimbium | Nosint | Volcis;
(CI) Côte d'Ivoire: Nimbex;
(CN) China: Cisatracurium besylate | Nimbex;
(CO) Colombia: Alurium | Besilato de cisatracurio | Cirium | Cisatracurio | Kabicurium | Miocurim | Neurocuriox | Nimbium | Salatracurio | Tracurion;
(CZ) Czech Republic: Cisatracurium hospira | Cisatracurium kabi | Cisatracurium kalceks | Nimbex;
(DE) Germany: Cisatracurium | Cisatracurium accord | Cisatracurium actavis | Cisatracurium hexal | Cisatracurium kabi | Cisatracurium Ratiopharm | Cisatracurium Teva | Nimbex;
(DO) Dominican Republic: Besilato de cisatracurio;
(EC) Ecuador: Cis | Cistrac | Nimbex | Nimbium | Tracurion;
(EE) Estonia: Cisatracurium norameda | Nimbex | Nimbex forte;
(EG) Egypt: Nimbex;
(ES) Spain: Cisatracurio Combino | Cisatracurio combino pharm | Cisatracurio Hospira | Cisatracurio inibsa | Cisatracurio kabi | Cisatracurio normon | Cisatracurio pfizer | Cisatracurio sala | Cisatracurio teva | Cisatracurium kalceks | Nimbex;
(FI) Finland: Cisatracurium accord | Cisatracurium norameda | Nimbex;
(FR) France: Cisatracurium | Cisatracurium accord | Cisatracurium hospira | Cisatracurium kabi | Cisatracurium kalceks | Cisatracurium mylan | Nimbex;
(GB) United Kingdom: Cisatracurium | Nimbex | Nimbex forte;
(GR) Greece: Catren | Cisatracurium/kabi | Cisatracurium/teva | Cisatral | Nimbex;
(HK) Hong Kong: Cisatracurium besylate | Cisatracurium kabi | Cisatracurium normon | Nimbex;
(HU) Hungary: Cisatracurium actavis | Cisatracurium kabi | Cisatracurium kalceks | Nimbex;
(IN) India: Cisatra | Cisblok;
(IT) Italy: Cisatracurio accord | Cisatracurio Actavis | Cisatracurio hikma | Cisatracurio kabi | Cisatracurio mylan | Cisatracurio sandoz | Cisatracurio teva | Nimbex;
(JO) Jordan: Nimbex;
(KE) Kenya: Cis curon | Nimbex;
(KR) Korea, Republic of: Nimbex;
(KW) Kuwait: Nimbex;
(LB) Lebanon: Nimbex;
(LT) Lithuania: Cisatracurium kabi | Cisatracurium kalceks | Cisatracurium norameda | Nimbex;
(LU) Luxembourg: Nimbex;
(LV) Latvia: Cisatracurium kabi | Cisatracurium kalceks | Cisatracurium norameda | Nimbex;
(MX) Mexico: Bensitrak | Cicuryl | Cisatracurio | Nimbex;
(MY) Malaysia: Cisatracurium kabi | Nimbex;
(NL) Netherlands: Cisatracurium accord | Cisatracurium Fresenius Kabi | Nimbex;
(NO) Norway: Cisatracurio accord | Cisatracurium accord | Nimbex;
(PE) Peru: Nimbex;
(PH) Philippines: Nimbex;
(PK) Pakistan: Cis curon;
(PL) Poland: Cisatracurium accord | Cisatracurium actavis | Cisatracurium hospira | Cisatracurium kabi | Cisatracurium kalceks | Cisatracurium mylan | Cisatracurium Noridem;
(PR) Puerto Rico: Cisatracurium besylate | Nimbex;
(PT) Portugal: Cisatracurio Combino | Cisatracurio Hospira | Cisatracurio kabi | Cisatracurio normon;
(QA) Qatar: Nimbex | Nimbex Forte | Nimbex PF;
(RO) Romania: Nimbex;
(RU) Russian Federation: Cisatracurii besilas | Nimbex;
(SA) Saudi Arabia: Cis tac | Nimbex | Salocan | Traxia;
(SE) Sweden: Nimbex;
(SG) Singapore: Nimbex;
(SI) Slovenia: Nimbex;
(SK) Slovakia: Nimbex;
(TH) Thailand: Cisatracurium kabi | Nimbex;
(TN) Tunisia: Cisatrex | Nimbex;
(TR) Turkey: Nimbex;
(TW) Taiwan: Cisatracurium kabi | Nimbex;
(UA) Ukraine: Cisatracurium kalceks;
(ZA) South Africa: Cisatracurium | Cisatracurium safeline | Cistrax | Nimbex;
(ZM) Zambia: Nimbex;
(ZW) Zimbabwe: Nimbex

Ahlfors CE. Benzyl alcohol, kernicterus, and unbound bilirubin. J Pediatr. 2001;139(2):317-319. [PubMed 11487763]
Alhazzani W, Belley-Cote E, Møller MH, et al. Neuromuscular blockade in patients with ARDS: a rapid practice guideline. Intensive Care Med. 2020;46(11):1977-1986. doi:10.1007/s00134-020-06227-8 [PubMed 33104824]
American Society of Health-System Pharmacists (ASHP). Pediatric continuous infusion standards. Available at https://www.ashp.org/-/media/assets/pharmacy-practice/s4s/docs/Pediatric-Infusion-Standards.ashx. Updated September 2023. Accessed September 27, 2023.
Atherton DP, Hunter JM. Clinical pharmacokinetics of the newer neuromuscular blocking drugs. Clin Pharmacokinet. 1999;36(3):169-189. doi:10.2165/00003088-199936030-00001 [PubMed 10223167]
Barash PG, Cullen BF, Stoelting RK, et al. Neuromuscular blocking agents. Clin Anesth. 2017;8(21):527-563.
Baumann, MH, McAlpin BW, Brown K, et al, “A Prospective Randomized Comparison of Train-of-Four Monitoring and clinical Assessment During Continuous ICU Cisatracurium Paralysis,” Chest, 2004, 126(4):1267-73. [PubMed 15486392]
Belmont MR, Lien CA, Quessy S, et al. The clinical neuromuscular pharmacology of 51W89 in patients receiving nitrous oxide/opioid/barbiturate anesthesia. Anesthesiology. 1995;82(5):1139-1145. doi:10.1097/00000542-199505000-00008 [PubMed 7741288]
Berkow LC. Rapid sequence induction and intubation (RSII) for anesthesia. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed January 29, 2024.
Breslin DS, Jiao K, Habib AS, et al, “Pharmacodynamic Interactions Between Cisatracurium and Rocuronium,” Anesth Analg, 2004, 98(1):107-10. [PubMed 14693597]
Burmester M, Mok Q. Randomised controlled trial comparing cisatracurium and vecuronium infusions in a paediatric intensive care unit. Intensive Care Med. 2005;31(5):686-692. [PubMed 15815895]
Centers for Disease Control (CDC). Neonatal deaths associated with use of benzyl alcohol—United States. MMWR Morb Mortal Wkly Rep. 1982;31(22):290-291. http://www.cdc.gov/mmwr/preview/mmwrhtml/00001109.htm [PubMed 6810084]
Cisatracurium besylate [prescribing information]. Princeton, NJ: Sandoz Inc; August 2018.
Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med. 2021;49(11):e1063-e1143. doi:10.1097/CCM.0000000000005337 [PubMed 34605781]
Expert opinion. Senior Obesity Editorial Team: Jeffrey F. Barletta, PharmD, FCCM; Manjunath P. Pai, PharmD, FCP; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC.
Fodale V, Santamaria LB. Laudanosine, an atracurium and cisatracurium metabolite. Eur J Anaesthesiol. 2002;19(7):466-473. doi:10.1017/s0265021502000777 [PubMed 12113608]
Greenberg SB, Vender J. The use of neuromuscular blocking agents in the ICU: where are we now? Crit Care Med. 2013;41(5):1332-1344. doi:10.1097/CCM.0b013e31828ce07c [PubMed 23591211]
Gropper M, Eriksson L, Fleisher L, Wiener-Kronish J, Cohen N, Leslie K. Miller’s Anesthesia, 9th ed. Churchill Livingstone. 2020.
Han TH, Martyn JA. Onset and effectiveness of rocuronium for rapid onset of paralysis in patients with major burns: priming or large bolus. Br J Anaesth. 2009;102(1):55-60. [PubMed 19029093]
"Inactive" ingredients in pharmaceutical products: update (subject review). American Academy of Pediatrics (AAP) Committee on Drugs. Pediatrics. 1997;99(2):268-278. [PubMed 9024461]
Institute for Safe Medication Practices (ISMP). 2020-2021 ISMP Targeted Medication Safety Best Practices for Hospitals. https://www.ismp.org/sites/default/files/attachments/2020-02/2020-2021%20TMSBP-%20FINAL_1.pdf. Accessed August 5, 2020.
Konstadt SN, Reich DL, Stanley TE 3d, et al, “A Two Center Comparison of the Cardiovascular Effects of Cisatracurium (Nimbex®) and Vecuronium in Patients With Coronary Artery Disease,” Anesth Analg, 1995, 81(5):1010-4. [PubMed 7486039]
Lagneau F, D’honneur G, Plaud B, et al, “A Comparison of Two Depths of Prolonged Neuromuscular Blockade Induced by Cisatracurium in Mechanically Ventilated Critically Ill Patients,” Intensive Care Med, 2002, 28(12):1735-41. [PubMed 12447516]
Leykin Y, Pellis T, Lucca M, Lomangino G, Marzano B, Gullo A. The effects of cisatracurium on morbidly obese women. Anesth Analg. 2004;99(4):1090-1094, table of contents. doi:10.1213/01.ANE.0000132781.62934.37 [PubMed 15385356]
Lien CA, Belmont MR, Abalos A, et al, “The Cardiovascular Effects and Histamine-Releasing Properties of 51W89 in Patients Receiving Nitrous Oxide/Opioid/Barbiturate Anesthesia,” Anesthesiology, 1995, 82(5):1131-8. [PubMed 7537945]
Madden LK, Hill M, May TL, et al. The implementation of targeted temperature management: an Evidence-Based Guideline from the Neurocritical Care Society. Neurocrit Care. 2017;27(3):468-487. doi: 10.1007/s12028-017-0469-5. [PubMed 29038971]
Martin LD, Bratton SL, O'Rourke PP. Clinical uses and controversies of neuromuscular blocking agents in infants and children. Crit Care Med. 1999;27(7):1358-1368. [PubMed 10446832]
Miller RD. Miller’s Anesthesia, 7th ed. Philadelphia PA: Churchill Livingstone, 2010.
Murray MJ, Cowen J, DeBlock H, et al, “Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient. Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists, American College of Chest Physicians,” Crit Care Med, 2002, 30(1):142-56. [PubMed 11902255]
Murray MJ, DeBlock H, Erstad B, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2016;44(11):2079-2103. doi:10.1097/CCM.0000000000002027. [PubMed 27755068]
Murray KL, Wright D, Laxton B, Miller KM, Meyers J, Englebright J. Implementation of standardized pediatric i.v. medication concentrations. Am J Health Syst Pharm. 2014;71(17):1500-1508. [PubMed 25147175]
Naguib M, Flood P, McArdle JJ, Brenner HR. Advances in neurobiology of the neuromuscular junction. Implications for the anesthesiologist. Anesthesiology. 2002;96(1):202-31. [PubMed 11753022]
Nimbex (cisatracurium besylate) [prescribing information]. North Chicago, IL: AbbVie Inc; October 2022.
Papazian L, Forel JM, Gacouin A, et al; ACURASYS Study Investigators. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107-1116. doi: 10.1056/NEJMoa1005372. [PubMed 20843245]
Playfor S, Jenkins I, Boyles C, et al. Consensus guidelines for sustained neuromuscular blockade in critically ill children. Paediatr Anaesth. 2007;17(9):881-887. [PubMed 17683408]
Prielipp RC, Coursin DB, Scuderi PE, et al, “Comparison of the Infusion Requirements and Recovery Profiles of Vecuronium and Cisatracurium 51W89 in Intensive Care Unit Patients,” Anesth Analg, 1995, 81(1):3-12. [PubMed 7598277]
Reece-Stremtan S, Campos M, Kokajko L; Academy of Breastfeeding Medicine. ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother, revised 2017. Breastfeed Med. 2017;12(9):500-506. doi:10.1089/bfm.2017.29054.srt [PubMed 29624435]
Refer to manufacturer's labeling.
Reich DL, Hollinger I, Harrington DJ, Seiden HS, Chakravorti S, Cook DR. Comparison of cisatracurium and vecuronium by infusion in neonates and small infants after congenital heart surgery. Anesthesiology. 2004;101(5):1122-1127. [PubMed 15505447]
Salihoĝlu Z, Demiroluk S, Köse Y, Zengin K, Taskin M, Gökay BV. Neuromuscular effects of cisatracurium in morbidly obese patients. Middle East J Anaesthesiol. 2008;19(4):831-839. [PubMed 18630769]
Schmith VD, Fiedler-Kelly J, Phillips L, Grasela TH Jr. Prospective use of population pharmacokinetics/pharmacodynamics in the development of cisatracurium. Pharm Res. 1997;14(1):91-97. doi:10.1023/a:1012015719694 [PubMed 9034227]
Sinclair-Pingel J, Grisso AG, Hargrove FR, Wright L. Implementation of standardized concentrations for continuous infusions using a computerized provider Order Entry System [published correction appears in Hosp Pharm. 2007; 42:84-85]. Hosp Pharm. 2006;41:1102-1106.
Solatpour F, Teymourian H, Mohajerani SA, er al. Comparison of the incidence of sore throat after rapid sequence intubation with succinylcholine and cisatracurium. Anesth Pain Med. 2014;4(3):e20030. doi:10.5812/aapm.20030 [PubMed 25289376]
Sorooshian SS, Stafford MA, Eastwood NB, et al, “Pharmacokinetics and Pharmacodynamics of Cisatracurium in Young and Elderly Adult Patients,” Anesthesiology, 1996, 84(5):1083-91. [PubMed 8624002]
Thilen SR, Weigel WA, Todd MM, et al. 2023 American Society of Anesthesiologists practice guidelines for monitoring and antagonism of neuromuscular blockade: a report by the American Society of Anesthesiologists task force on neuromuscular blockade. Anesthesiology. 2023;138(1):13-41. doi:10.1097/ALN.0000000000004379 [PubMed 36520073]
Tobias JD. A prospective evaluation of the continuous infusion of cis-atracurium for neuromuscular blockade in the pediatric intensive care unit patient: efficacy and dosage requirements. Am J Ther. 1997;4(9-10):287-290. [PubMed 10423621]
Xu QA, Zhang YP, Trissel LA, et al, “Stability of Cisatracurium Besylate in Vials, Syringes, and Infusion Admixtures,” Am J Health Syst Pharm, 1998, 55(10) :1037-41. [PubMed 9606456]

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Cisatracurium: Pediatric drug information