From the Guidelines
Cisatracurium is not recommended as a first-line agent for Rapid Sequence Intubation (RSI) due to its slow onset of action compared to other available options. The most recent and highest quality study, published in 2023 in Critical Care Medicine 1, suggests that either rocuronium or succinylcholine should be administered for RSI when there are no known contraindications to succinylcholine. This recommendation is based on the need for rapid paralysis in emergency situations, which cisatracurium cannot provide due to its onset of action of 2-3 minutes.
Key Considerations for RSI
- The goal of RSI is to achieve rapid airway control, which requires fast-acting neuromuscular blocking agents.
- Succinylcholine and rocuronium are preferred agents for RSI due to their rapid onset of action, with succinylcholine having an onset of 30-60 seconds and rocuronium having an onset of 45-60 seconds.
- Cisatracurium, with its slower onset, may be considered in specific cases where faster-acting agents are contraindicated or unavailable, but this would require careful consideration of the patient's condition and the urgency of intubation.
Evidence Supporting Preferred Agents
- A study published in 2023 in Critical Care Medicine 1 highlights the importance of rapid sequence intubation and suggests the use of either rocuronium or succinylcholine, citing their faster onset of action as a critical factor in emergency situations.
- Another study from 2019 in Anaesthesia 1 discusses the management of the child's airway under anesthesia and also favors succinylcholine for its rapid action, although it notes rocuronium as a good alternative under certain conditions.
Clinical Decision Making
In clinical practice, the decision to use cisatracurium for RSI should be made with caution, taking into account the patient's specific needs, potential contraindications to faster-acting agents, and the ability to modify the RSI protocol to accommodate the slower onset of cisatracurium. The primary consideration should always be the patient's safety and the achievement of rapid, secure airway control.
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 muscle relaxants like succinylcholine and rocuronium 3.
- A study compared the intubating conditions after administering rocuronium or cisatracurium in a rapid sequence induction with remifentanil-propofol, and 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 RSI has been explored in various studies, including one that examined the duration and recovery profile of cisatracurium after succinylcholine during propofol or isoflurane anesthesia, and found that the duration of action of cisatracurium is dose-dependent during propofol and isoflurane anesthetics 4.
- Another study discussed the use of atracurium, a related compound to cisatracurium, in rapid-sequence induction, and found that atracurium can be an alternative to succinylcholine when used according to the "timing principle" 5.
- However, it is worth noting that cisatracurium is not as commonly used as other muscle relaxants like rocuronium for RSI, and its use may be limited by its slower onset time and higher cost 6, 3.
Comparison with Other Muscle Relaxants
- Succinylcholine is still the most frequently used muscle relaxant for RSI due to its fast onset and short duration of action, but it has well-known side-effects 6.
- Rocuronium is an alternative to succinylcholine for RSI, and can provide good intubating conditions with a faster onset time compared to cisatracurium 6, 3.
- Atracurium, a related compound to cisatracurium, has been used in RSI and can provide good intubating conditions when used according to the "timing principle" 5.
Clinical Considerations
- The choice of muscle relaxant for RSI depends on various factors, including the patient's medical history, the type of surgery, and the anesthesiologist's preference 6, 3.
- Cisatracurium may be a good option for RSI in certain situations, such as when a patient has a contraindication to succinylcholine or rocuronium, or when a longer duration of action is desired 3, 4.