Cisatracurium is an intermediate-acting neuromuscular blocking agent used in both hospitalized and outpatient settings as an adjunct to general anesthesia. It facilitates tracheal intubation and provides skeletal muscle relaxation during surgical procedures or mechanical ventilation in ICU patients.

Adults: Initial Doses: One of two intubating doses of Cisatracurium may be chosen, based on the desired time to tracheal intubation and the anticipated length of surgery. In addition to the dose of neuromuscular blocking agent, the presence of co-induction agents (e.g. fentanyl and midazolam) and the depth of anesthesia are factors that can influence intubation conditions. Doses of 0.15 (3 × ED95 ) and 0.20 (4 × ED95 ) mg/kg Cisatracurium, as components of a propofol/nitrous oxide/oxygen induction-intubation technique, may produce generally GOOD or EXCELLENT conditions for intubation in 2.0 and 1.5 minutes, respectively. Similar intubation conditions may be expected when these doses of Cisatracurium are administered as components of a thiopental/nitrous oxide/oxygen induction-intubation technique. In two intubation studies with thiopental or propofol and midazolam and fentanyl as co-induction agents, EXCELLENT intubation conditions were most frequently achieved with the 0.2 mg/kg compared to 0.15 mg/kg dose of cisatracurium. The clinically effective durations of action for 0.15 and 0.20 mg/kg Cisatracurium during propofol anesthesia are 55 minutes (range: 44 to 74 minutes) and 61 minutes (range: 41 to 81 minutes), respectively. Lower doses may result in a longer time for the development of satisfactory intubation conditions. Doses up to 8 × ED95 Cisatracurium have been safely administered to healthy adult patients and patients with serious cardiovascular disease. These larger doses are associated with longer clinically effective durations of action.

Children: Initial Doses: The recommended dose of Cisatracurium for children 2 to 12 years of age is 0.10–0.15 mg/kg administered over 5 to 10 seconds during either halothane or opioid anesthesia. When administered during stable opioid/nitrous oxide/oxygen anesthesia, 0.10 mg/kg Cisatracurium produces maximum neuromuscular block in an average of 2.8 minutes (range: 1.8 to 6.7 minutes) and clinically effective block for 28 minutes (range: 21 to 38 minutes). When administered during stable opioid/nitrous oxide/oxygen anesthesia, 0.15 mg/kg Cisatracurium produces maximum neuromuscular block in about 3.0 minutes (range: 1.5 to 8.0 minutes) and clinically effective block (time to 25% recovery) for 36 minutes (range: 29 to 46 minutes).

Infants: Initial Doses: The recommended dose of Cisatracurium for intubation of infants 1 month to 23 months is 0.15 mg/kg administered over 5 to 10 seconds during either halothane or opioid anesthesia. When administered during stable opioid/nitrous oxide/oxygen anesthesia, 0.15 mg/kg Cisatracurium produces maximum neuromuscular block in about 2.0 minutes (range: 1.3 to 3.4 minutes) and clinically effective block (time to 25% recovery) for about 43 minutes (range: 34 to 58 minutes).

Cisatracurium can be safely used after recovery from succinylcholine-induced neuromuscular blockade. Prior use of succinylcholine may slightly accelerate the onset of action of Cisatracurium but does not significantly affect its duration.

Certain inhalational anesthetics such as isoflurane or enflurane may prolong the duration of action of Cisatracurium and reduce infusion requirements, especially during prolonged surgical procedures. Propofol has minimal effect on its action. Drugs that may enhance the neuromuscular blocking effect include aminoglycosides, tetracyclines, bacitracin, polymyxins, lincomycin, clindamycin, magnesium salts, lithium, local anesthetics, procainamide, and quinidine. Chronic use of anticonvulsants such as phenytoin or carbamazepine may reduce the duration of action and increase dosage requirements.

Cisatracurium is contraindicated in patients with known hypersensitivity to the drug or any of its components. The multi-dose vial formulation containing benzyl alcohol should not be used in premature infants.

Like all medicines, Cisatracurium injection may cause side effects, although not everyone experiences them. If any unusual symptoms occur, consult a healthcare professional.

Allergic reactions (very rare):

• Sudden wheezing, chest pain, or tightness
• Swelling of eyelids, face, lips, mouth, or tongue
• Skin rash or hives
• Severe reactions such as collapse or shock

Common:

• Decrease in heart rate
• Drop in blood pressure

Uncommon:

• Skin rash or redness
• Wheezing or coughing

Very rare:

• Muscle weakness or aching

Pregnancy Category B. It is not known whether Cisatracurium Besylate is excreted in human milk. Caution should be exercised when administered to nursing mothers.

Due to its intermediate onset, Cisatracurium is not recommended for rapid sequence intubation. It generally has minimal effect on heart rate and does not counteract bradycardia caused by anesthetic agents or vagal stimulation. Patients with neuromuscular disorders (e.g., myasthenia gravis) may experience increased sensitivity, requiring careful dose adjustment and monitoring. Burn patients may develop resistance and require higher doses. Electrolyte imbalance or acid-base disturbances may alter the drug’s effects. Regular neuromuscular monitoring is advised. Intramuscular administration is not recommended due to lack of sufficient data.

Keep out of sight and reach of children. Do not use after the expiry date. Store in a refrigerator (2°C–8°C). Do not freeze. Keep in original packaging to protect from light.