Cisatracurium besylate is a non-depolarizing neuromuscular blocking agent (NMBA) of the benzylisoquinolinium class. It is an intermediate-duration muscle relaxant used as an adjunct to general anesthesia to facilitate endotracheal intubation and provide skeletal muscle relaxation during surgery or mechanical ventilation. It is the 1R-cis 1'R-cis isomer of atracurium, accounting for approximately 15% of the mixture, and is 3-4 times more potent. It is a preferred agent in the Indian ICU and OR settings due to its predictable pharmacokinetics, organ-independent Hofmann elimination, and minimal histamine release.
Adult: Intubation: 0.15 to 0.2 mg/kg IV bolus. Maintenance: 0.03 mg/kg IV bolus as required, OR continuous infusion at 1-3 mcg/kg/min (0.06-0.18 mg/kg/hr). Dosage MUST be individualized based on monitoring with a peripheral nerve stimulator.
Note: For IV use only. Must be administered by or under the direct supervision of an experienced anesthesiologist or intensivist. Bolus dose should be given as a rapid IV injection over 5-10 seconds. For continuous infusion, dilute in a compatible IV solution (e.g., 0.9% NaCl, 5% Dextrose) to a concentration of 0.1-0.4 mg/mL. Use a controlled infusion device. Neuromuscular function MUST be monitored continuously with a peripheral nerve stimulator (e.g., train-of-four). Do not mix with alkaline solutions (e.g., sodium thiopentone) in the same syringe or infusion line.
Cisatracurium is a competitive antagonist at the nicotinic acetylcholine receptors (nAChRs) of the postjunctional membrane at the neuromuscular junction (NMJ). It binds to the alpha subunits of the receptor, preventing acetylcholine (ACh) from binding and depolarizing the motor endplate. This inhibition prevents the generation of an action potential, leading to flaccid paralysis of skeletal muscles.
Pregnancy: Category B: Animal studies have shown no risk, but no adequate and well-controlled studies in pregnant women. Should be used only if clearly needed, typically during Caesarean section. Does not cross the placenta in significant amounts due to its quaternary structure.
Driving: Patients must be advised that residual muscle weakness may occur post-operatively. They should not drive or operate machinery until full muscle strength and coordination have returned, as certified by the treating physician.
| Aminoglycosides (Gentamicin, Amikacin) | Potentiate neuromuscular blockade, leading to prolonged apnea. | Major |
| Volatile Anesthetics (Isoflurane, Sevoflurane, Desflurane) | Potentiate the depth and duration of neuromuscular blockade. Dose reduction of cisatracurium by 15-40% may be required. | Moderate |
| Magnesium Sulfate | Potentiates neuromuscular blockade. | Major |
| Opioids (Fentanyl, Morphine) | May enhance bradycardic effects. | Moderate |
| Calcium Channel Blockers (Verapamil) | May enhance neuromuscular blocking effect. | Moderate |
| Local Anesthetics (Lidocaine IV) | May potentiate blockade. | Moderate |
| Corticosteroids (long-term, e.g., Dexamethasone) | Associated with critical illness myopathy/polyneuropathy, complicating recovery from paralysis. | Moderate |
| Acetylcholinesterase Inhibitors (Neostigmine, Pyridostigmine) | Antagonize the neuromuscular blockade. Used for reversal. | Therapeutic |
Same composition (Cisatracurium (10mg)), different brands: