What are the loading and maintenance bolus doses of Cisatracurium (cisatracurium besylate)?

From the Guidelines

Cisatracurium should be administered with a loading dose of 0.1–0.2 mg/kg and maintenance bolus doses as needed, based on the patient's response and monitoring of neuromuscular function, as it offers non-enzymatic plasma degradation and is preferred in renal and hepatic impairment. When considering the use of cisatracurium, it is essential to weigh the benefits and limitations of this medication. The loading dose of 0.1–0.2 mg/kg is recommended, with maintenance bolus doses given as needed, typically every 35–45 minutes, as the duration of action is approximately 35–45 min 1.

Key Considerations

• The choice of cisatracurium is particularly advantageous in patients with renal and hepatic impairment due to its non-enzymatic plasma degradation 1.
• Monitoring of neuromuscular function using a peripheral nerve stimulator is crucial to adjust dosing and ensure adequate surgical relaxation.
• Cisatracurium's pharmacokinetic profile makes it a preferred agent in certain patient populations, such as those with organ impairment.

Comparison with Other Agents

• Other neuromuscular blockers like atracurium, rocuronium, and vecuronium have different profiles in terms of duration of action, metabolism, and potential side effects 1.
• The selection of a neuromuscular blocker should be based on the individual patient's needs and the specific clinical scenario.

Clinical Context

• In the context of sedation and shivering management after cardiac arrest, the use of neuromuscular blockers like cisatracurium may be necessary to control shivering during targeted temperature management 1.
• It is crucial to consider the cardiovascular effects of sedatives and the potential for neuromuscular blockers to suppress shivering in patients with cardiogenic shock.

From the FDA Drug Label

Doses of 0.15 (3 x ED95) and 0.2 (4 x ED95) mg/kg cisatracurium, as components of a propofol/nitrous oxide/oxygen induction-intubation technique, may produce generally GOOD or EXCELLENT conditions for intubation in 2 and 1. 5 minutes, respectively. A dose of 0. 03 mg/kg cisatracurium is recommended for maintenance of neuromuscular block during prolonged surgical procedures. Maintenance doses of 0.03 mg/kg each sustain neuromuscular block for approximately 20 minutes.

The recommended loading dose of cisatracurium is 0.15-0.2 mg/kg to produce good or excellent intubation conditions. The recommended maintenance bolus dose is 0.03 mg/kg, which sustains neuromuscular block for approximately 20 minutes 2.

From the Research

Cisatracurium Loading and Maintenance Bolus Doses

• The currently recommended loading dose of cisatracurium may not lead to the desired pharmacodynamic response in critically ill patients with respiratory failure 3.
• A study found that a loading dose of 0.2 mg/kg of cisatracurium resulted in a mean time to train-of-four 0/4 of 6 ± 3.86 minutes, with only 10% of patients achieving the desired pharmacodynamic response in less than 5 minutes 3.
• Another study compared the doses required for complete paralysis after induction of anesthesia in ICU patients with the dose used in patients undergoing elective surgery, and found that the cumulative doses of cisatracurium were significantly higher in the ICU group 4.
• A high bolus dose of cisatracurium (8x ED95) given at induction can provide muscle relaxation for the major part of a cardiac procedure with hypothermic cardiopulmonary bypass, but may not cover the entire intraoperative period and can result in a high incidence of movements 5.
• The median stable dose of cisatracurium in a critically ill ARDS population was found to be 2.8 (2.0,3.1) μg/kg/min, with acute kidney injury (AKI) being a factor independently associated with steady-state dose requirements 6.
• A study found that careful conduction, monitoring, and subsequent reversal of neuromuscular block with cisatracurium or rocuronium can result in a low incidence of residual neuromuscular block, but some mid- and long-term cases of TOF ratios <0.9 can still occur 7.

Factors Affecting Cisatracurium Dosing

• Patient characteristics such as albumin levels, partial pressure of carbon dioxide, and respiratory alkalosis can affect the pharmacokinetics and pharmacodynamics of cisatracurium 3.
• Acute kidney injury (AKI) has been found to be a factor independently associated with steady-state dose requirements of cisatracurium 6.
• Temperature, pH, and age may also affect the dose requirements of cisatracurium, although the evidence is limited 6.

Clinical Implications

• The dosing of cisatracurium for ICU patients should be individualized and based on careful monitoring of neuromuscular function 4.
• A high bolus dose of cisatracurium may not be suitable for all patients, and a continuous infusion may be a better option for maintaining muscle relaxation during surgery 5.
• The use of neuromuscular monitoring and careful reversal of neuromuscular block can help minimize the risk of residual neuromuscular block 7.