From the Guidelines
Cisatracurium is suitable for Rapid Sequence Intubation.
Key Points
- Cisatracurium has been studied in large RCTs and is the preferred agent for neuromuscular blockade in patients with ARDS 1.
- The typical dose of cisatracurium used in these studies was a 15 mg bolus followed by an infusion of 37.5 mg/h for 48 h 1.
- Cisatracurium has a rapid recovery profile, with recovery of a TOF ratio >0.7 occurring within 34-85 minutes after drug discontinuation 1.
- The use of cisatracurium for rapid sequence intubation is supported by its neuromuscular blockade effect and potential anti-inflammatory effect 1.
Considerations
- Clinicians may titrate the dose of cisatracurium to clinical paralytic effect, as the relationships between dose and clinical and adverse effects are unclear 1.
- The potential benefits and harms of using cisatracurium should be considered when making decisions about its use 1.
From the FDA Drug Label
Because of its intermediate onset of action, cisatracurium is not recommended for rapid sequence endotracheal intubation.
Cisatracurium is not suitable for Rapid Sequence Intubation due to its intermediate onset of action 2.
From the Research
Cisatracurium for Rapid Sequence Intubation
- Cisatracurium is a non-depolarizing muscle relaxant with a slower onset of action compared to other agents like rocuronium 3.
- The recommended intubating dose of cisatracurium is 0.15 to 0.2 mg/kg, which is 3 to 4 times the ED95 3.
- Studies have shown that cisatracurium provides good-to-excellent intubating conditions within 2-3 minutes when used at a dose of 0.2 mg/kg or 0.3 mg/kg 4.
- However, the onset of action of cisatracurium is significantly slower than that of rocuronium, with a mean time to onset of 188 ± 40.88 seconds for cisatracurium compared to 92 ± 7.61 seconds for rocuronium 5.
- Despite its slower onset, cisatracurium can provide comparable intubating conditions to rocuronium when used in a rapid sequence induction with remifentanil and propofol 6.
Comparison with Other Agents
- Rocuronium has a faster onset of action and is often preferred for rapid sequence intubation 3, 5.
- Atracurium, a related agent to cisatracurium, can also provide acceptable intubating conditions when used at high doses (1 mg/kg) during rapid sequence induction 7.
- Cisatracurium has a more stable hemodynamic profile compared to other agents, with minimal changes in heart rate and blood pressure 4, 6.
Clinical Use
- Cisatracurium may be a suitable alternative to other non-depolarizing muscle relaxants for rapid sequence intubation, particularly when used at higher doses (0.2 mg/kg or 0.3 mg/kg) 4.
- However, its slower onset of action should be taken into consideration when choosing a muscle relaxant for rapid sequence intubation 5.
- The choice of muscle relaxant ultimately depends on the individual patient's needs and the clinical scenario 3, 6.