Cisatracurium Dosing and Usage for Tracheal Intubation and Surgery
Initial Intubating Doses
For tracheal intubation, administer cisatracurium 0.15-0.2 mg/kg IV, with the 0.2 mg/kg dose providing superior intubation conditions at 1.5 minutes compared to 2 minutes with 0.15 mg/kg. 1
Standard Dosing Protocol
0.15 mg/kg (3 x ED95): Produces good to excellent intubation conditions in 2 minutes with a clinically effective duration of 55 minutes (range: 44-74 minutes) 1
0.2 mg/kg (4 x ED95): Produces excellent intubation conditions in 1.5 minutes with a clinically effective duration of 61 minutes (range: 41-81 minutes), and is the preferred dose for optimal intubation conditions 1, 2
Both doses achieve good or excellent intubation conditions in over 90% of patients when used with propofol/nitrous oxide/oxygen or thiopental-based induction techniques 1, 2
Mechanism and Rationale
Cisatracurium is a benzylisoquinolinium non-depolarizing neuromuscular blocking agent that competitively binds cholinergic receptors at the motor end plate 3
The use of muscle relaxants like cisatracurium reduces poor intubating conditions from 24.6% to 4.1% and decreases pharyngeal/laryngeal injury from 18.7-22.6% to 9.7% 4, 3
Maintenance Dosing During Surgery
Administer 0.03 mg/kg cisatracurium for maintenance of neuromuscular blockade, which sustains block for approximately 20 minutes. 1
Maintenance Timing
First maintenance dose typically required 40-50 minutes after initial 0.15 mg/kg dose 1
First maintenance dose typically required 50-60 minutes after initial 0.2 mg/kg dose 1
Subsequent maintenance doses should be guided by clinical criteria and train-of-four (TOF) monitoring 1
Continuous Infusion Alternative
After initial bolus, cisatracurium can be administered by continuous infusion for extended procedures in adults and children ≥2 years 1
Infusion rates should be individualized based on TOF monitoring 1
Special Population Adjustments
Elderly and Renal Dysfunction Patients
Extend the interval between cisatracurium administration and intubation attempt due to slower onset times in these populations 1
No dose adjustment necessary due to organ-independent Hofmann elimination 3, 1
Obese Patients
- Calculate cisatracurium dose based on ideal body weight, not actual body weight 3
Pediatric Dosing
Children 2-12 years: 0.1-0.15 mg/kg produces maximum block in 2.8-3 minutes with 28-36 minutes of clinically effective block 1
Infants 1-23 months: 0.15 mg/kg produces maximum block in approximately 2 minutes with 43 minutes of clinically effective block 1
Volatile Anesthetic Interactions
Isoflurane or enflurane at 1.25 MAC prolongs the duration of cisatracurium, requiring less frequent or lower maintenance doses. 1
Initial 15-30 minutes of volatile agent exposure has minimal effect on initial dose requirements 1
No initial dose adjustment needed when cisatracurium is administered shortly after volatile agent initiation 1
In prolonged procedures with volatile anesthetics, reduce maintenance dose frequency or amount 1
No dose adjustment required with propofol anesthesia 1
Monitoring Requirements
Use peripheral nerve stimulator monitoring to optimize cisatracurium dosing and minimize risk of overdosage or underdosage. 1
Train-of-four monitoring is mandatory throughout anesthesia 5
Target TOF ratio ≥0.9 at adductor pollicis to eliminate residual neuromuscular blockade 5
Recovery to TOF ratio >0.7 occurs within 34-85 minutes after discontinuation 3
Reversal Considerations
Administer neostigmine 0.05 mg/kg plus glycopyrrolate 10 mcg/kg when tactile TOF count reaches 2 or more to ensure TOF ratio >0.7 in the PACU. 6
When neostigmine reversal is delayed until TOF count ≥2, postoperative weakness (TOF <0.7) should be rare 6
At 10 minutes post-reversal, expect TOF ratios of approximately 0.72-0.76 6
By 15 minutes post-reversal, nearly all patients achieve TOF ratio ≥0.7 6
Critical Pitfalls and Caveats
ICU Patients Require Higher Doses
ICU patients require significantly higher cumulative doses (10 ± 4.7 ED95) compared to elective surgery patients (3 ± 0.3 ED95) due to altered pharmacodynamics 7
The standard 0.15 mg/kg dose fails to achieve complete paralysis in ICU patients, requiring repeated boluses 7
Neuromuscular monitoring is essential in ICU settings due to unpredictable response 7
Laryngeal Muscle Considerations
Cisatracurium has slower onset at laryngeal muscles (196 seconds with 0.1 mg/kg) compared to equipotent atracurium doses due to higher potency 8
The 0.15 mg/kg dose achieves 92% maximum blockade at the larynx, while 0.2 mg/kg achieves 100% blockade in 148 seconds 8