From the Guidelines
Nimbex (Cisatracurium) is a suitable alternative for Rapid Sequence Intubation (RSI), particularly in patients with renal or hepatic failure, due to its unique pharmacokinetic properties. The recommended dose of Nimbex for RSI is 0.15-0.2 mg/kg IV, which provides intubating conditions within 90-120 seconds 1. This makes it a viable option when other agents like succinylcholine or rocuronium may not be ideal. Key advantages of Nimbex include its metabolism through Hofmann elimination, which is not significantly affected by liver or kidney function, as evidenced by the guidelines recommending not to modify the initial dose in renal/hepatic failure patients 1. Additionally, Nimbex has minimal histamine release and cardiovascular effects, making it beneficial for hemodynamically unstable patients. When using Nimbex for RSI, it is crucial to:
- Ensure appropriate airway equipment is ready
- Pre-oxygenate the patient adequately
- Administer a sedative agent, such as etomidate 0.3 mg/kg or ketamine 1-2 mg/kg, immediately before the paralytic
- Continue sedative medications after intubation, as Nimbex does not provide analgesia or sedation. Given its properties and the recommendation to use the standard dose in patients with renal or hepatic failure 1, Nimbex can be a valuable agent in the arsenal for RSI, especially in complex cases.
From the FDA Drug Label
PRECAUTIONS: Because of its intermediate onset of action, cisatracurium is not recommended for rapid sequence endotracheal intubation. The role of Nimbex (Cisatracurium) in Rapid Sequence Intubation (RSI) is that it is not recommended due to its intermediate onset of action 2.
From the Research
Role of Nimbex (Cisatracurium) in Rapid Sequence Intubation (RSI)
- The provided studies do not directly discuss the role of Nimbex (Cisatracurium) in Rapid Sequence Intubation (RSI) in detail, but some information can be inferred from the characteristics of Cisatracurium mentioned in one of the studies 3.
- Cisatracurium is described as approximately 4 times more potent than atracurium, with a slower onset time compared to equipotent doses of atracurium 3.
- The recommended intubating dose of Cisatracurium is 0.15 to 0.2 mg/kg (3 to 4 times ED95), and its recovery properties are not affected by the size of the bolus dose or the duration of infusion 3.
- Unlike some other neuromuscular blockers, Cisatracurium does not trigger histamine release and undergoes Hofmann elimination, with about 77% of the drug cleared by organ-dependent mechanisms 3.
- While the studies primarily compare Rocuronium and Succinylcholine for RSI, the characteristics of Cisatracurium suggest it could be considered for RSI, especially in patients where histamine release is a concern or when a neuromuscular blocker with a predictable recovery profile is desired 3, 4, 5, 6, 7.
Comparison with Other Neuromuscular Blockers
- Rocuronium and Succinylcholine are more commonly discussed in the context of RSI, with studies comparing their efficacy, onset times, and side effects 4, 6, 7.
- The choice between these agents often depends on the specific clinical scenario, including the patient's medical history, the urgency of the intubation, and the potential for difficult intubation 5, 7.