From the Guidelines
Cisatracurium is not recommended for Rapid Sequence Intubation (RSI) due to its slow onset of action, which is not suitable for the urgent airway management required in RSI scenarios. The most recent and highest quality study, 1, suggests administering either rocuronium or succinylcholine for RSI when there are no known contraindications to succinylcholine, due to their faster onset of paralysis. Some key points to consider when choosing a neuromuscular blocking agent (NMBA) for RSI include:
- The need for rapid intubation, which requires a fast-acting NMBA like succinylcholine or rocuronium
- The potential risks and benefits of each NMBA, including the risk of awareness and the need for post-intubation analgosedation
- The importance of protocolized care and the incorporation of personnel, such as clinical pharmacists, to improve the timeliness of analgosedation implemented. While cisatracurium is an effective NMBA, its slower onset of action makes it less suitable for RSI, and it should only be considered in rare cases where faster-acting agents are contraindicated and rapid intubation is less critical, as stated in 1 and 1.
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 rocuronium 3.
- A study found that despite its slower onset time, cisatracurium can provide good intubating conditions comparable to those achieved with equipotent doses of rocuronium when used in anesthesia induced with remifentanil and propofol 3.
- The choice of muscle relaxant for RSI is crucial, and succinylcholine is still the most frequently used due to its fast onset and recovery, but it has well-known side-effects 4.
- Rocuronium is an alternative to succinylcholine for RSI, especially in large doses, but its use may be limited by dose-dependent respiratory side-effects 4.
- The optimal dose and timing of neuromuscular blocking drugs, including cisatracurium, are still controversial and require further study 5.
- Cisatracurium has a dose-dependent duration of action, and its recovery profile is affected by the type of anesthesia used, such as propofol or isoflurane 6.
- While rocuronium is often compared to succinylcholine for RSI, cisatracurium is not directly compared to succinylcholine in the available studies, but its use as an alternative is suggested by its comparable intubating conditions to rocuronium 3, 7.