Cisatracurium

Cisatracurium is a neuromuscular blocking agent (muscle relaxant) given intravenously in clinical settings. It is approved for the following uses:

• To help place a breathing tube (tracheal intubation) during general anesthesia in adults and in children 1 month through 12 years of age
• To relax skeletal muscles during surgery in adults
• To relax skeletal muscles during surgery in pediatric patients 2 to 12 years of age, given as a single bolus dose or as a continuous infusion
• To provide muscle relaxation for adults on mechanical ventilation in the ICU
• Not recommended for rapid-sequence intubation — a fast emergency airway technique — because its onset of action is too slow for that use

Cisatracurium works by competitively blocking the receptors at the neuromuscular junction — the point where a nerve signal would normally trigger a muscle to contract. It prevents acetylcholine (the body's own chemical messenger for muscle movement) from binding to those receptors, so the muscle stays relaxed. When muscle relaxation is no longer needed, clinicians can reverse this blockade with cholinesterase inhibitors such as neostigmine or edrophonium, which boost acetylcholine levels enough to overcome the blockade.

Importantly, cisatracurium breaks down through a process called Hofmann elimination — a chemical reaction dependent on body temperature and pH — rather than relying heavily on the liver or kidneys. This means its clearance is relatively predictable across most patients, though its metabolites (including one called laudanosine) do depend on kidney and liver function for clearance.

Cisatracurium is given exclusively by intravenous (IV) injection or continuous IV infusion in a hospital or clinical setting. It is never taken at home or by mouth. Dosing is individualized — the clinical team uses a peripheral nerve stimulator to continuously monitor the depth of muscle blockade and adjust the amount given based on each patient's response.

• It may be given as a single bolus (one-time) dose or as a continuous infusion, depending on the procedure and setting
• In certain patient groups — including older adults, those with kidney disease, and those with neuromuscular conditions — the timing or amount may be adjusted
• Specific doses are determined by the treating clinical team; always follow their guidance

Cisatracurium is generally well tolerated, but some reactions can occur:

• Slow heart rate (bradycardia)
• Low blood pressure (hypotension)
• Flushing (skin redness)
• Bronchospasm (airway tightening)
• Skin rash
• Prolonged neuromuscular block (muscle weakness lasting longer than expected after the procedure)
• Muscle weakness or myopathy (muscle damage), reported after use
• Histamine release (can cause flushing or bronchospasm)
• Anaphylaxis (severe allergic reaction), reported rarely but potentially life-threatening

Serious reactions — including anaphylaxis, severe breathing difficulty, or unexpected prolonged paralysis — require immediate emergency management by the clinical team.

• Risk of death from medication errors: Accidental administration to the wrong patient causes paralysis and can lead to respiratory arrest and death. Cisatracurium must be stored and labeled carefully, and administered only by trained clinicians with resuscitation equipment immediately available.
• Residual paralysis: Some patients — particularly those with neuromuscular diseases like myasthenia gravis — may have lingering muscle weakness after the procedure. Patients should not be removed from ventilatory support until adequate muscle function is confirmed.
• Risk of seizures with long-term use: A breakdown product called laudanosine can accumulate in patients with kidney or liver impairment who receive cisatracurium for extended periods. Laudanosine has caused seizures in animals; nerve monitoring helps keep doses minimal.
• Benzyl alcohol toxicity in infants: The 10 mL multiple-dose vials contain benzyl alcohol, which can cause fatal reactions including 'gasping syndrome' in newborns and low birth-weight infants. These vials are contraindicated in patients under 1 month of age and low birth-weight infants.
• Severe hypersensitivity and anaphylaxis: Life-threatening allergic reactions have been reported. Cross-reactivity with other neuromuscular blocking agents is possible.
• Must be used with adequate anesthesia: Cisatracurium paralyzes muscles but does not cause unconsciousness or block pain. It must always be used alongside appropriate sedation or general anesthesia.

Several drugs can significantly change how cisatracurium works — either making the blockade stronger and longer, or making it shorter and less effective:

• Inhalational anesthetics (isoflurane, enflurane): When used for more than 30 minutes, these can prolong the duration of blockade and lower the infusion rate needed — by as much as 30–40%
• Certain antibiotics (aminoglycosides, tetracyclines, clindamycin, bacitracin, polymyxins, lincomycin, colistin, sodium colistimethate): can prolong neuromuscular blockade
• Magnesium salts: enhance the blocking effect — particularly relevant in pregnant patients receiving magnesium for preeclampsia or eclampsia
• Local anesthetics, procainamide, lithium, quinidine: may prolong neuromuscular blockade
• Succinylcholine: if given before cisatracurium, can speed up the onset of blockade but does not affect how long it lasts
• Phenytoin and carbamazepine (anti-seizure medications): can reduce the duration of blockade, meaning higher or more frequent doses may be needed

This is not a complete list of interactions. Always talk with your doctor or pharmacist before starting, stopping, or changing any medication.

• Tell the care team about any known allergy to cisatracurium or any other neuromuscular blocking agent — cross-reactions between these agents have been reported
• Patients with neuromuscular diseases (such as myasthenia gravis, myasthenic syndrome) or carcinomatosis are at higher risk for residual paralysis and require a lower starting dose
• Patients with kidney or liver impairment may accumulate metabolites (including laudanosine) during extended use, increasing seizure risk
• The 10 mL multiple-dose vials contain benzyl alcohol and are contraindicated in infants under 1 month of age and low birth-weight infants; benzyl alcohol-free 5 mL or 20 mL single-dose vials are available
• Pregnant patients: if cisatracurium is needed, the benzyl alcohol-free single-dose vials are preferred; magnesium used for preeclampsia can enhance the drug's effect
• Breastfeeding: data on cisatracurium in breast milk are not available; discuss with the care team
• Older adults: blockade takes about 1 minute longer to peak — the clinical team will allow extra time before intubation
• Patients with end-stage renal disease: onset is slightly slower — similar timing adjustment applies
• Patients with hemiparesis or paraparesis: nerve monitoring should be performed on the non-affected limb
• Patients with burns, or undergoing coronary artery bypass surgery with induced hypothermia: dosing may need adjustment — the treating team will account for this

Too much cisatracurium will prolong muscle paralysis beyond what is needed, including the muscles used to breathe. The primary treatment is maintaining a clear airway and providing controlled mechanical ventilation until normal muscle function returns on its own. Once partial recovery begins, a cholinesterase inhibitor such as neostigmine or edrophonium may be given (alongside an appropriate supporting medication) to speed reversal — but these reversal agents should not be given while complete paralysis is still present, as they may not be strong enough to restore adequate breathing on their own.

Cisatracurium produces dose-dependent skeletal muscle relaxation. Higher doses result in faster onset and longer duration of blockade. In adults, doubling the dose extends the clinically effective duration by about 25 minutes. Once recovery begins, its speed is independent of how much drug was given. Pediatric patients (including infants) generally reach peak blockade faster and recover more quickly than adults given the same weight-based dose. Notably, cisatracurium does not cause meaningful changes in heart rate or blood pressure across the studied dose range.

Cisatracurium is broken down primarily through a process called Hofmann elimination — a spontaneous chemical reaction driven by normal body temperature and pH that does not depend on the liver or kidneys. This accounts for roughly 80% of its clearance, making its behavior relatively predictable across patients. Its elimination half-life (the time for blood levels to drop by half) is about 22 minutes in healthy adults. The remaining 20% of clearance involves the kidneys and liver, which are the main pathways for clearing its metabolites — including laudanosine — meaning those metabolites can linger longer in patients with kidney or liver impairment.

Refrigerate Cisatracurium Besylate Injection, USP at 2° to 8°C (36° to 46°F) in the carton to preserve potency. Protect from light. DO NOT FREEZE.