From the Guidelines
Cisatracurium can be safely used in patients with impaired renal function undergoing dialysis. Unlike many other neuromuscular blocking agents, cisatracurium undergoes organ-independent Hofmann elimination in plasma and tissues, which means its clearance is not significantly affected by kidney dysfunction 1. The standard intubating dose of 0.15-0.2 mg/kg IV followed by maintenance doses of 0.03 mg/kg as needed can be used without dose adjustment in renal failure patients. For continuous infusion, the typical rate of 1-3 mcg/kg/min can be maintained.
Key Considerations
- Monitoring with a peripheral nerve stimulator is still essential to guide dosing and assess recovery.
- Cisatracurium's metabolism produces laudanosine, which can accumulate in renal failure, but the concentrations reached are generally not clinically significant even with prolonged use.
- This pharmacokinetic profile makes cisatracurium a preferred neuromuscular blocking agent in the setting of renal impairment, as it provides predictable onset, duration of action, and recovery regardless of renal function status, as recommended by clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient 1.
Clinical Recommendations
- Use cisatracurium for patients with significant hepatic or renal disease due to its unique metabolism 1.
- Assess patients receiving NMBAs both clinically and by TOF monitoring, with a goal of adjusting the degree of neuromuscular blockade to achieve one or two twitches 1.
From the FDA Drug Label
The time to 90% neuromuscular blockade was 1 minute slower in patients with end-stage renal disease than in patients with normal renal function. Therefore, consider extending the interval between administering Cisatracurium Besylate Injection and attempting intubation by at least 1 minute to achieve adequate intubation conditions [see Dosage and Administration (2. 2) and Clinical Pharmacology (12.2)]. There was no clinically significant alteration in the recovery profile of Cisatracurium Besylate Injection in patients with end-stage renal disease following a 0. 1 mg/kg dose of Cisatracurium Besylate Injection. The recovery profile of Cisatracurium Besylate Injection is unchanged in patients with renal impairment, which is consistent with predominantly organ-independent elimination [see Clinical Pharmacology (12.3)].
Cisatracurium can be used in patients with impaired renal function undergoing dialysis. However, the time to maximum neuromuscular blockade may be slower, and the interval between administration and intubation attempt should be extended by at least 1 minute. The recovery profile of cisatracurium is unchanged in patients with renal impairment due to its predominantly organ-independent elimination 2.
- Key considerations:
- Extend the interval between administering cisatracurium and attempting intubation by at least 1 minute.
- Monitor patients closely for any signs of prolonged neuromuscular blockade.
- Adjust the dosage and administration schedule as needed to ensure adequate intubation conditions and recovery from neuromuscular blockade.
From the Research
Cisatracurium Use in Patients with Impaired Renal Function
- Cisatracurium is a non-depolarizing neuromuscular blocking agent that can be used in patients with impaired renal function undergoing dialysis 3, 4.
- The drug is metabolized mainly by the Hofmann elimination pathway (77%), with a smaller proportion being metabolized by organ-dependent modes, including the kidney (16%) 3.
- Studies have shown that cisatracurium is a suitable choice for patients with renal failure, with minimal changes in pharmacodynamic parameters compared to patients with normal renal function 4.
- However, patients with renal failure may exhibit a slightly prolonged recovery time with a wide inter-individual variety, highlighting the need for intraoperative neuromuscular monitoring 4.
Pharmacokinetics and Neuromuscular Blocking Effects
- The pharmacokinetics of atracurium, a related compound, and its metabolites have been studied in patients with normal and impaired renal function 5, 6.
- Renal failure has been shown to affect the pharmacokinetic profile of laudanosine, a metabolite of atracurium, with a longer terminal half-life and increased volume of distribution in patients with impaired renal function 5, 6.
- The neuromuscular blocking effects of atracurium may be altered in patients with renal failure, with some studies suggesting a shorter duration of neuromuscular blockade and recovery index in these patients 6.
Clinical Use in Patients with Renal Failure
- Cisatracurium has been used in patients with renal failure on an intensive care unit, with satisfactory clinical control and rapid spontaneous recovery when the infusion is stopped 7.
- However, larger doses may be required in oedematous patients, and careful monitoring of neuromuscular function is necessary to ensure optimal patient care 7.
- The use of cisatracurium in patients with impaired renal function undergoing dialysis should be guided by the patient's individual needs and response to the drug, with careful consideration of the potential risks and benefits 3, 4.