Cisatracurium Dosing for Surgical Procedures
For routine surgical intubation in adults, administer cisatracurium 0.15-0.2 mg/kg IV as an initial bolus dose, with 0.15 mg/kg providing good-to-excellent intubation conditions in 2 minutes and 0.2 mg/kg in 1.5 minutes. 1
Initial Intubation Dosing
Standard Adult Dosing
- 0.15 mg/kg (3 × ED95): Produces good or excellent intubation conditions in 2 minutes with a clinically effective duration of 55 minutes (range: 44-74 minutes) during propofol anesthesia 1, 2
- 0.2 mg/kg (4 × ED95): Achieves intubation conditions in 1.5 minutes with a duration of 61 minutes (range: 41-81 minutes), with excellent conditions achieved more frequently than with 0.15 mg/kg 1, 2
Pediatric Dosing
- Children (2-12 years): 0.1-0.15 mg/kg IV over 5-10 seconds during halothane or opioid anesthesia 1
- Infants (1-23 months): 0.15 mg/kg IV over 5-10 seconds, producing maximum block in 2 minutes with 43 minutes of clinically effective duration 1
Maintenance Dosing
Administer 0.03 mg/kg cisatracurium for maintenance of neuromuscular blockade during prolonged procedures, which sustains block for approximately 20 minutes. 1
- Maintenance dosing typically required 40-50 minutes after 0.15 mg/kg initial dose 1
- Maintenance dosing typically required 50-60 minutes after 0.2 mg/kg initial dose 1
- Use peripheral nerve stimulator (train-of-four monitoring) to determine timing of maintenance doses rather than fixed intervals 1
Continuous Infusion Dosing
For extended surgical procedures, after an initial bolus, cisatracurium can be administered by continuous infusion 1:
- ICU patients with ARDS (PaO2/FiO2 <150): Administer as continuous IV infusion at 2.5 μg/kg/min for 48 hours early in the course of ARDS, which reduces 28-day mortality 3
- General surgical infusion: Initiate at 3 μg/kg/min following initial bolus dose 3
Special Population Considerations
Elderly and Renal Dysfunction Patients
- Extend the interval between cisatracurium administration and intubation attempt, as slower onset times are observed in these populations 1
- No dose adjustment required, but allow additional time for adequate intubation conditions to develop 1
Volatile Anesthetic Interactions
- No adjustment to initial dose needed when cisatracurium is administered shortly after initiation of isoflurane or enflurane (first 15-30 minutes of 1.25 MAC exposure) 1
- Reduce maintenance dose frequency or amount during prolonged enflurane or isoflurane anesthesia, as these agents prolong the duration of action 1
- No dose adjustment required with propofol anesthesia 1
ICU Patients
ICU patients require significantly higher cumulative doses (approximately 10 × ED95 vs 3 × ED95) compared to elective surgery patients due to altered pharmacodynamics and delayed onset. 4
- Standard anesthesia dosing (0.15 mg/kg) fails to produce complete paralysis in ICU patients 4
- Mandatory use of neuromuscular monitoring in ICU settings 4
Critical Safety Considerations
Monitoring Requirements
- Use peripheral nerve stimulator for all cisatracurium administration to minimize overdosage/underdosage risk and assess recovery 1
- Target train-of-four (TOF) ratio >0.9 before extubation 3
- Continue quantitative monitoring after reversal agent administration until TOF ratio ≥0.9 3
Cardiovascular Stability
- Cisatracurium does not cause histamine release even at high doses (up to 8 × ED95), unlike atracurium 1, 5, 6
- No significant changes in heart rate, blood pressure, or intracranial pressure with bolus administration 3, 6
- Superior hemodynamic profile compared to atracurium in neurosurgical patients 6
Common Pitfalls to Avoid
- Do not use fixed time intervals for maintenance dosing—always use neuromuscular monitoring to guide redosing 1
- Avoid underdosing in ICU patients—standard surgical doses are inadequate in critically ill patients 4
- Do not assume adequate recovery without objective monitoring—clinical assessment alone is unreliable 3