From the Guidelines
Cisatracurium is not the preferred agent for Rapid Sequence Intubation (RSI) due to its slower onset of action compared to succinylcholine or rocuronium, but it can be considered in specific situations where faster-acting agents are contraindicated or unavailable. The most recent and highest quality study, published in 2023 in the journal Critical Care Medicine 1, suggests that rocuronium or succinylcholine should be used for RSI when there are no known contraindications to succinylcholine. However, cisatracurium could be an alternative in certain situations, with a typical dose of 0.15-0.2 mg/kg, which would need to be given earlier in the RSI process to account for its slower onset.
Key Considerations
- The onset of action of cisatracurium is slower compared to succinylcholine or rocuronium, which may not provide ideal conditions for rapid intubation.
- The use of cisatracurium for RSI may require modifications to the standard RSI protocol and could potentially increase the risk of aspiration due to the longer time to achieve adequate paralysis.
- Healthcare providers should be aware of the potential risks and benefits of using cisatracurium for RSI and consider alternative agents when possible.
Relevant Evidence
- A study published in 2023 in the journal Critical Care Medicine 1 suggests that rocuronium or succinylcholine should be used for RSI when there are no known contraindications to succinylcholine.
- Another study published in 2023 in the same journal 1 provides recommendations for the use of neuromuscular-blocking agents (NMBAs) in RSI, including the suggestion to administer either rocuronium or succinylcholine when there are no known contraindications to succinylcholine.
- The evidence from these studies suggests that cisatracurium is not the preferred agent for RSI, but it can be considered in specific situations where faster-acting agents are contraindicated or unavailable.
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 effectiveness compared to other neuromuscular blocking agents is still being studied 3.
- A study comparing cisatracurium and rocuronium for intubation in anesthesia induced by remifentanil and propofol found that despite fundamentally slower onset time, cisatracurium can provide quite good intubating conditions, which were comparable to those achieved with equipotent doses of rocuronium 3.
- However, the use of cisatracurium for RSI is not as well-established as other agents like rocuronium or succinylcholine, and more research is needed to determine its efficacy and safety in this context.
Comparison with Other Agents
- Rocuronium has been suggested as an alternative to succinylcholine for RSI, but studies have shown that succinylcholine is superior in achieving excellent intubating conditions 4, 5, 6.
- Atracurium, another non-depolarizing neuromuscular blocking agent, has been shown to provide acceptable intubating conditions when used in high doses (1 mg/kg) during RSI 7.
- The choice of neuromuscular blocking agent for RSI depends on various factors, including the patient's medical history, the urgency of the procedure, and the anesthesiologist's preference.
Key Findings
- Cisatracurium can provide good intubating conditions, but its onset time is slower compared to rocuronium 3.
- High-dose atracurium (1 mg/kg) can provide acceptable intubating conditions during RSI 7.
- Succinylcholine is still considered the gold standard for RSI due to its fast onset and short duration, but it can have serious side effects 4, 5, 6.