From the Guidelines
Cisatracurium is not the preferred choice for Rapid Sequence Intubation (RSI) due to its relatively slow onset of action, typically taking 2-3 minutes to achieve optimal intubating conditions. RSI requires a neuromuscular blocking agent with rapid onset to quickly secure the airway in emergency situations. Better alternatives for RSI include succinylcholine (1-1.5 mg/kg IV), which works within 45-60 seconds, or rocuronium (1-1.2 mg/kg IV), which provides good intubating conditions in about 60-90 seconds 1.
Key Considerations
- Succinylcholine offers the fastest onset but has numerous contraindications including hyperkalemia, burns, crush injuries, and certain neuromuscular disorders.
- Rocuronium at higher doses is the preferred alternative when succinylcholine is contraindicated.
- While cisatracurium offers advantages like minimal histamine release and organ-independent elimination through Hofmann degradation, making it useful for patients with liver or kidney dysfunction, these benefits don't outweigh its slow onset when rapid airway control is needed 1.
Clinical Context
In true emergency situations requiring immediate airway management, the speed of onset is the critical factor that makes cisatracurium a suboptimal choice for RSI. However, cisatracurium may be preferred in certain clinical contexts, such as patients with ARDS, where its potential anti-inflammatory effects may be beneficial 1. Nevertheless, in the context of RSI, the primary concern is rapid airway control, and cisatracurium's slow onset makes it less ideal. Therefore, succinylcholine or rocuronium should be considered as the first-line agents for RSI, unless contraindicated.
From the FDA Drug Label
PRECAUTIONS: Because of its intermediate onset of action, cisatracurium is not recommended for rapid sequence endotracheal intubation.
Cisatracurium is not recommended for Rapid Sequence Intubation (RSI) due to its intermediate onset of action 2.
From the Research
Cisatracurium for Rapid Sequence Intubation (RSI)
- Cisatracurium can be used for RSI, but its onset time is slower compared to other neuromuscular blocking agents like rocuronium and succinylcholine 3, 4.
- A study comparing cisatracurium and rocuronium for intubation in anesthesia induced by remifentanil and propofol found that despite its slower onset time, cisatracurium can provide good intubating conditions comparable to those achieved with equipotent doses of rocuronium 3.
- The use of cisatracurium in critical care has been reviewed, and it has been found to have favorable pharmacological characteristics compared to other neuromuscular blocking agents 5.
- However, cisatracurium is more expensive than comparable agents, and some safety concerns persist regarding adverse events associated with the drug 5.
Comparison with Other Neuromuscular Blocking Agents
- Rocuronium has been suggested as an alternative to succinylcholine for intubation, but a Cochrane review found that succinylcholine is superior to rocuronium for achieving excellent intubating conditions 6.
- A prospective, randomized controlled trial comparing succinylcholine and rocuronium for RSI in intensive care found that there was no difference between the two agents regarding oxygen desaturations, intubation conditions, and failed first intubation attempts 7.
- A study comparing the onset time, duration of action, and intubating conditions after cisatracurium in young and elderly patients found that elderly patients had a longer onset time and duration of action compared to younger patients, but no difference was found in intubating conditions 4.
Intubating Conditions and Safety
- Cisatracurium has been found to provide good intubating conditions, but its slower onset time may be a concern in certain situations 3, 4.
- The safety of cisatracurium has been reviewed, and it has been found to have a favorable safety profile, but some concerns persist regarding adverse events associated with the drug 5.
- A study found that a larger proportion of elderly patients reported hoarseness 24 hours postoperatively after receiving cisatracurium 4.