AHFS Class:

• Neuromuscular Blocking Agents 12:20.20

Generic Name(s):

• Cisatracurium Besylate

Cisatracurium besylate, a benzylisoquinolone nondepolarizing neuromuscular blocking agent, is an isomer of atracurium.1,3,5,6,7,11,14,15,19,20

Skeletal Muscle Relaxation

Cisatracurium besylate is used to produce skeletal muscle relaxation during surgery after general anesthesia has been induced.1,5,11,20,21 The drug also is used to facilitate endotracheal intubation; however, a neuromuscular blocking agent with a rapid onset of action (e.g., succinylcholine, rocuronium) generally is preferred in emergency situations when rapid intubation is required.21,424 Cisatracurium is not recommended for rapid sequence intubation because of its intermediate onset of action.1,5,11,21,22

Cisatracurium also is used to facilitate mechanical ventilation in the intensive care unit (ICU).1,2,3,5,8,10,14,21,45,46 The drug has been given as a continuous IV infusion for up to 6 days in this setting; longer durations of use have not been evaluated.1 Whenever neuromuscular blocking agents are used in the ICU, the benefits versus risks of such therapy must be considered and patients should be assessed frequently to determine the need for continued paralysis.21

Compared with other neuromuscular blocking agents, cisatracurium has an intermediate onset and duration of action.1,20 In clinical studies, cisatracurium was administered at a rate of infusion one-third that of atracurium and exhibited a similar time to spontaneous recovery.1,7,8,9,13 Studies comparing cisatracurium with vecuronium showed a longer duration of action and faster time to spontaneous recovery with cisatracurium.1,10,11,12,13,14 Cisatracurium has minimal, if any, cardiovascular effects and causes less histamine release than atracurium.1,3,20,21 Because cisatracurium (and atracurium) undergo Hofmann degradation and are not dependent on renal or hepatic pathways for elimination, these neuromuscular blocking agents may be particularly useful in patients with hepatic or renal impairment; some experts prefer the use of cisatracurium or atracurium if prolonged therapy is necessary in ICU patients with multiple organ dysfunction.1,3,20,21

For additional information on uses and treatment principles of neuromuscular blocking agents, see Uses in the Neuromuscular Blocking Agents General Statement 12:20.20.

Administration

Cisatracurium is administered IV only.1

Commercially available 20-mL single-dose vials of cisatracurium besylate containing 10 mg/mL are intended for intensive care unit (ICU) use only .1

IV Administration

The initial (intubating) dose of cisatracurium is administered by rapid IV injection; maintenance doses may be administered by intermittent IV injection or continuous IV infusion.1

For continuous IV infusion, cisatracurium besylate injection should be diluted to the desired concentration (e.g., 0.1-0.4 mg/mL) in a compatible IV solution (5% dextrose, 0.9% sodium chloride, or 5% dextrose and 0.9% sodium chloride injection).1,48 Continuous IV infusions of cisatracurium have been administered for up to 3 hours without evidence of cumulative neuromuscular blocking effects; such administration has no effect on duration of blockade, provided partial recovery is allowed to occur between doses.1,48 The rate of spontaneous neuromuscular recovery following discontinuance of the infusion is likely to be comparable to the rate of recovery following administration of a single IV injection of the drug.1

Cisatracurium besylate injection should be stored at 2-8°C and protected from light prior to use; the drug should not be frozen.1 Once removed from refrigeration, the injection should be used within 21 days, regardless of whether it was subsequently returned to refrigeration.1 Following dilution, the infusion solution should be used within 24 hours.1

Standardize 4 Safety

Standardized concentrations for cisatracurium have been established through Standardize 4 Safety (S4S), a national patient safety initiative to reduce medication errors, especially during transitions of care. 249,250Multidisciplinary expert panels were convened to determine recommended standard concentrations. 249,250Because recommendations from the S4S panels may differ from the manufacturer's prescribing information, caution is advised when using concentrations that differ from labeling, particularly when using rate information from the label. 249,250 For additional information on S4S (including updates that may be available), see[Web].249,250

Rate of Administration

Initial (intubating) doses of cisatracurium are administered by direct IV injection, usually over 5-10 seconds.1

Continuous IV infusion rates should be individualized based on patient requirements and response to peripheral nerve stimulation.1,48 (See Tables 2 and 3 for recommended rates of infusion.)1 Accurate dosage is best achieved using a precision infusion device.1,359

Dispensing and Administration Precautions

Neuromuscular blocking agents should be administered only by individuals who are adequately trained in their use and complications.1,359 For specific procedures and techniques of administration, specialized references should be consulted. Facilities and personnel necessary for intubation, administration of oxygen, and respiratory support should be immediately available whenever these drugs are used.1,359,424 In addition, a reversal agent should be readily available in the event of a failed intubation or to accelerate neuromuscular recovery after surgery.1,21,359

Because neuromuscular blocking agents can cause respiratory arrest, precautions (e.g., storage segregation, warning labels, access limitations) should be taken to ensure that these drugs are not administered without adequate respiratory support.425 Affixing warning labels to storage containers and final administration containers is recommended to clearly communicate that respiratory paralysis can occur and ventilator support is required.425 The Institute for Safe Medication Practices (ISMP) recommends the following wording for these containers: “Warning: Paralyzing agent—causes respiratory arrest—patient must be ventilated.”425

Neuromuscular blocking agents have no known effect on consciousness, pain, or cerebration, and should therefore be used in conjunction with adequate levels of anesthesia, and only after appropriate analgesics and sedatives are administered.1,21,359,423 To avoid distress to the patient, cisatracurium should be administered only after unconsciousness has been induced.1,3,21,424

Dosage

Dosage of cisatracurium besylate is expressed in terms of cisatracurium.1

Dosage of cisatracurium must be carefully adjusted according to individual requirements and response.1,21 The use of a peripheral nerve stimulator is recommended to accurately monitor the degree of neuromuscular blockade and recovery, determine the need for additional doses, and minimize the possibility of overdosage.1,3,21,48

Skeletal Muscle Relaxation in Pediatric Patients

Initial (Intubating) Dose

The recommended initial intubating dose of cisatracurium in infants 1-23 months of age when used concomitantly with halothane or opiate anesthesia is 0.15 mg/kg.1 This dose generally produces maximum neuromuscular blockade in about 2 minutes and clinically effective blockade for about 43 minutes.1

The recommended initial intubating dose of cisatracurium in children 2-12 years of age when used concomitantly with halothane or opiate anesthesia is 0.1-0.15 mg/kg.1 A dose of 0.1 mg/kg administered under these conditions can be expected to produce maximum neuromuscular blockade in about 2.8 minutes and clinically effective blockade for about 28 minutes, and a dose of 0.15 mg/kg can be expected to produce maximum neuromuscular blockade in about 3 minutes and clinically effective blockade for about 36 minutes.1

The manufacturer makes no specific dosage recommendations for adolescents 13 years of age or older.1,48

Maintenance Dosage During Prolonged Surgical Procedures

After the initial intubating dose is administered, children 2 years of age or older may receive a continuous IV infusion of cisatracurium to maintain neuromuscular blockade during prolonged surgical procedures.1,48 The infusion should be initiated only after early spontaneous recovery from the initial dose is evident.1 The rate of infusion should be individualized based on patient response to peripheral nerve stimulation.1 An initial rate of 3 mcg/kg per minute may be necessary to rapidly counteract spontaneous neuromuscular recovery; thereafter, a rate of 1-2 mcg/kg per minute generally is sufficient to maintain neuromuscular blockade in the range of 89-99% in most pediatric patients receiving balanced anesthesia.1

A reduction in the cisatracurium infusion rate by up to 30-40% may be necessary if steady-state anesthesia has been induced with enflurane or isoflurane; greater reductions may be required with prolonged durations of enflurane or isoflurane administration.1

Skeletal Muscle Relaxation in Adults

Initial (Intubating) Dose

The recommended initial (intubating) dose of cisatracurium in adults is 0.15 or 0.2 mg/kg depending on the desired time to intubation and duration of the procedure.1 When used concomitantly with balanced anesthesia, good to excellent intubating conditions generally occur within 2 minutes following a dose of 0.15 mg/kg or 1.5 minutes following a dose of 0.2 mg/kg.1 A dose of 0.15 mg/kg generally produces maximum neuromuscular blockade in approximately 3.5 minutes and clinically sufficient neuromuscular blockade for about 55 minutes, and a dose of 0.2 mg/kg generally produces maximum neuromuscular blockade in approximately 2.9 minutes and clinically sufficient neuromuscular blockade for about 65 minutes.1

Maintenance Dosage During Prolonged Surgical Procedures

For maintenance of neuromuscular blockade during prolonged surgical procedures, additional cisatracurium doses of 0.03 mg/kg may be administered by intermittent IV injection in adults.1 The first maintenance dose generally is required within 40-50 or 50-60 minutes following an initial dose of 0.15 or 0.2 mg/kg, respectively.1,5 Each 0.03-mg/kg dose can provide approximately 20 minutes of additional neuromuscular blockade.1 Smaller or larger doses may be needed to provide shorter or longer durations of action.1

Less frequent or lower doses of cisatracurium may be necessary when administered concomitantly with enflurane or isoflurane anesthesia during prolonged surgical procedures.1 No dosage adjustment appears to be necessary when the drug is administered shortly (e.g., within 15-30 minutes) after initiation of the inhalation anesthetic.1

Alternatively, after the initial intubating dose is administered, patients may receive a continuous IV infusion of cisatracurium to maintain neuromuscular blockade during prolonged surgical procedures; the infusion should be initiated only after early spontaneous recovery from the initial dose is evident.1 Infusion rates should be individualized and adjusted based on patient response to peripheral nerve stimulation.1 An initial rate of 3 mcg/kg per minute may be necessary to rapidly counteract spontaneous recovery from neuromuscular blockade.1 Thereafter, a maintenance infusion rate of 1-2 mcg/kg per minute generally is sufficient to maintain neuromuscular blockade in the range of 89-99% in most patients receiving balanced anesthesia.1

A reduction in the cisatracurium infusion rate by up to 30-40% may be necessary if steady-state anesthesia has been induced with enflurane or isoflurane; greater reductions may be required with prolonged durations of enflurane or isoflurane administration.1

Maintenance Dosage in Intensive Care Setting

Cisatracurium may be administered by continuous IV infusion for maintenance of neuromuscular blockade during mechanical ventilation in the intensive care unit (ICU).1 The degree of neuromuscular blockade should be monitored with a peripheral nerve stimulator; additional doses should not be given before there is a definite response to nerve stimulation.1

In clinical studies, an average cisatracurium infusion rate of approximately 3 mcg/kg per minute was required for maintenance of neuromuscular blockade in mechanically ventilated adults in the ICU; however, dosage requirements may vary widely among patients and also may increase or decrease with time.1 In these studies, patients received up to 6 days of cisatracurium infusion; longer durations of use in the ICU have not been evaluated.1 Recovery of neuromuscular function (train-of-four [TOF] ratio of at least 0.7) generally occurred within approximately 50-55 minutes after the infusion was discontinued.1 Following neuromuscular recovery, administration of an IV (“bolus”) dose of cisatracurium may be necessary to reestablish neuromuscular blockade prior to reinstitution of the infusion.1

Reversal of Neuromuscular Blockade

Neuromuscular blockade induced by cisatracurium can be reversed by administering a cholinesterase inhibitor (e.g., neostigmine, pyridostigmine, edrophonium) in conjunction with an anticholinergic agent such as atropine or glycopyrrolate to block the adverse muscarinic effects of the cholinesterase inhibitor.1,21 For specific information on the uses and dosage and administration of these other drugs, see the individual monographs .

To minimize the risk of residual neuromuscular blockade, reversal should only be attempted after some degree of spontaneous recovery has occurred; patients should be closely monitored until adequate recovery of normal neuromuscular function is assured (i.e., ability to maintain satisfactory ventilation and a patent airway).1,21,355,356,357,358 Time to recovery of neuromuscular function is dependent upon the strength of neuromuscular blockade at the time of reversal.1

Special Populations

Renal Impairment

Since onset of complete neuromuscular blockade may be slower in patients with renal impairment, it may be necessary to extend the interval between administration of cisatracurium and the intubation attempt in such patients.1,16

Geriatric Patients

Since onset of complete neuromuscular blockade may be slower in geriatric patients, it may be necessary to extend the interval between administration of cisatracurium and the intubation attempt in such patients.1,16

Burn Patients

Substantially increased doses of cisatracurium may be required in burn patients due to the development of resistance.1 However, there are no clinical studies to date in these patients, and no specific doses are recommended .1

Cardiopulmonary Bypass Patients with Induced Hypothermia

The infusion rate of atracurium required to maintain adequate surgical relaxation during hypothermia (i.e., 25-28°C) is approximately 50% of the infusion rate necessary in normothermic patients; a similar reduction in the infusion rate of cisatracurium may be expected.1,15

Other Populations

A cisatracurium dose of 0.02 mg/kg or less is recommended along with monitoring of subsequent dosage adjustments in patients in whom potentiation of neuromuscular blockade or difficulties with reversal of blockade may occur (e.g., neuromuscular disease, carcinomatosis).1

Contraindications

Cisatracurium besylate is contraindicated in patients with known hypersensitivity to the drug or any of its components.1

Multiple-dose vials of cisatracurium containing benzyl alcohol are contraindicated in premature infants.1

Warnings/Precautions

Warnings

Cisatracurium shares the toxic potentials of the nondepolarizing neuromuscular blocking agents, and the usual precautions of neuromuscular blocking agent administration should be observed. (See Cautions in the Neuromuscular Blocking Agents General Statement 12:20.20.)

Administration Precautions

When used inappropriately, neuromuscular blocking agents can severely compromise respiratory function and induce respiratory paralysis; special precautions should be taken during and after administration of these drugs.1,21,23,359,424 The degree of neuromuscular blockade produced by cisatracurium should be monitored with a peripheral nerve stimulator, particularly in patients with conditions that may potentiate (e.g., neuromuscular diseases) or cause resistance to (e.g., burns) the neuromuscular blocking effects of the drug.1

Sensitivity Reactions

Hypersensitivity Reactions

Serious hypersensitivity reactions, including anaphylaxis, have been reported rarely with all neuromuscular blocking agents; such reactions were life-threatening or fatal in some cases.1 Appropriate emergency treatment should be readily available whenever these drugs are administered.1 Because of the possibility of cross-sensitivity, cisatracurium should be used with caution in patients who have experienced previous anaphylactic reactions to other neuromuscular blocking agents (depolarizing or nondepolarizing).1

General Precautions

Neuromuscular Diseases

Patients with neuromuscular diseases (e.g., myasthenia gravis, Eaton-Lambert syndrome) may have an exaggerated response to cisatracurium.1,23 In such patients, the degree of neuromuscular blockade should be monitored with a peripheral nerve stimulator and dosage reduction is recommended.1

Burn Patients

Resistance to nondepolarizing neuromuscular blocking agents,33,34,35,37,38 including atracurium, can develop in burn patients, particularly those with burns over 25-30% or more of body surface area.1,33,34,35,36,37,38,39

Cisatracurium has not been studied in this population; however, based on its similarity to atracurium, the possible need for substantially increased doses should be considered in such patients.1

Intensive Care Setting

Although the manufacturer states that continuous IV infusion of cisatracurium for up to 6 days in the intensive care unit (ICU) has been safely used in several studies,1 prolonged paralysis and/or muscle weakness have been reported with long-term administration of neuromuscular blocking agents.3,20

Continuous monitoring of neuromuscular transmission with a peripheral nerve stimulator is recommended whenever cisatracurium is used in the ICU.1,3,21,48 Additional doses of cisatracurium or any other neuromuscular blocking agent should not be administered before there is a definite response to nerve stimulation tests.1 If no response is elicited, administration of the drug should be discontinued until a response returns.1

Seizures have been reported rarely in patients receiving continuous IV infusions of atracurium for facilitation of mechanical ventilation in the ICU; these patients usually had predisposing factors (e.g., head trauma, cerebral edema, hypoxic encephalopathy, viral encephalitis, uremia).1,20 It is unclear whether laudanosine (a metabolite of atracurium and cisatracurium that produces CNS excitation at higher doses) contributes to CNS excitation.1

Cardiovascular Effects

Cisatracurium has no clinically important effects on heart rate at recommended doses and exhibits minimal, if any, cardiovascular effects;1,3,16,18,20 therefore, the drug will not counteract the bradycardia induced by many anesthetic agents or by vagal stimulation.1

Electrolyte Disturbances

Acid-base and/or serum electrolyte abnormalities may potentiate or antagonize the action of cisatracurium.1

Hemiparesis and Paraparesis

Resistance to cisatracurium may develop in the affected limbs of patients with hemiparesis or paraparesis.1 To avoid inaccurate dosing, neuromuscular monitoring in the nonparetic limb is recommended.1

Malignant Hyperthermia

Malignant hyperthermia is rarely associated with the use of neuromuscular blocking agents and/or potent inhalation anesthetics.1,20 In an animal study in susceptible swine, cisatracurium did not trigger malignant hyperthermia; however, the drug has not been studied in patients with increased susceptibility to this condition.1 Because malignant hyperthermia can occur even in the absence of a recognized precipitating factor, clinicians should be vigilant for its possible development and prepared to manage the condition in any patient undergoing general anesthesia.1

Carcinomatosis

Because of possible exaggerated response to cisatracurium in patients with carcinomatosis, the degree of neuromuscular blockade should be monitored carefully with a peripheral nerve stimulator; dosage reduction is recommended.1

Specific Populations

Pregnancy

Category B.1

It is not known whether use of cisatracurium during labor, delivery, or cesarean section has any effects on the fetus.1

Lactation

It is not known whether cisatracurium is distributed into milk.1 Because many drugs are distributed into human milk, caution is advised if the drug is used in nursing women.1

Pediatric Use

Safety and efficacy of cisatracurium have not been established in neonates (younger than 1 month of age).1

Each mL of cisatracurium besylate injection in multiple-dose vials contains 9 mg of benzyl alcohol.1 Although a causal relationship has not been established, administration of injections preserved with benzyl alcohol has been associated with toxicity in neonates.1,24,25,26,27,28,29 Toxicity appears to have resulted from administration of large amounts (i.e., 100-400 mg/kg daily) of benzyl alcohol in these neonates.25,27,28,29 Although use of drugs preserved with benzyl alcohol should be avoided in neonates whenever possible, the American Academy of Pediatrics (AAP) states that the presence of small amounts of the preservative in a commercially available injection should not proscribe its use when indicated in neonates.24

Pediatric patients may exhibit faster clearance of cisatracurium than adults.1 Onset of the drug is faster and duration is longer in pediatric patients compared with adults, and in infants compared with older children.1

In clinical studies, tracheal intubation was facilitated more reliably in children 1-4 years of age when cisatracurium was used in conjunction with halothane than when used in conjunction with opiates and nitrous oxide.1

Geriatric Use

No overall differences in safety and efficacy have been observed in geriatric patients relative to younger adults, but increased sensitivity of some older patients cannot be ruled out.1

Minor alterations in cisatracurium pharmacokinetics (e.g., prolonged half-life, slower onset of action) have been observed in geriatric patients compared with younger individuals; however, these changes were not associated with substantial differences in recovery profile.1

Cisatracurium half-life may be slightly prolonged in geriatric patients.1,6

Hepatic Impairment

Minor alterations in cisatracurium pharmacokinetics have been observed in patients with end-stage liver disease compared with healthy adults; however, these changes were not associated with substantial differences in recovery profile.1

Concentrations of cisatracurium metabolites may be increased after prolonged administration in patients with hepatic disease.1

Renal Impairment

The pharmacokinetic/pharmacodynamic and recovery profile of cisatracurium in patients with renal impairment is similar to that in healthy adults.1 Concentrations of cisatracurium metabolites may be increased after prolonged administration in patients with renal failure.1

Common Adverse Effects

Adverse effects were uncommon in clinical trials in patients who received cisatracurium in conjunction with anesthetic agents or other drugs (e.g., opiates, propofol) during surgery; no adverse effects were reported with an incidence exceeding 1% in these studies.1

Similarly, adverse effects were uncommon in ICU patients receiving cisatracurium, but several cases of prolonged recovery were reported.1

Concurrent administration of some drugs, including general anesthetics (e.g., enflurane, isoflurane), antibiotics (e.g., aminoglycosides, polymyxins), lithium, succinylcholine, magnesium salts, procainamide, and quinidine, may affect the neuromuscular blocking activity of cisatracurium besylate.1 For additional information on potential drug interactions of cisatracurium, see Drug Interactions in the Neuromuscular Blocking Agents General Statement 12:20.20 .

Anticonvulsants

Resistance to the neuromuscular blocking effects of cisatracurium may occur in patients receiving long-term phenytoin or carbamazepine therapy.1,3,30 Because this may result in a shorter duration of neuromuscular block, higher infusion rates of cisatracurium may be required.1,30

Anti-infective Agents

The possibility that some anti-infective agents (e.g., aminoglycosides, bacitracin, clindamycin, lincomycin, polymyxins, tetracyclines) may enhance the neuromuscular blocking effects of cisatracurium should be considered.1,3

General Anesthetics

Inhalation anesthetics (enflurane and isoflurane) are known to potentiate the effects of neuromuscular blocking agents.1,21,32 A reduction in cisatracurium dose and/or infusion rate may be necessary depending on the duration of administration of the inhalation anesthetic.1,32

Lithium

The neuromuscular blocking effects of cisatracurium may be enhanced by lithium.1,3

Local Anesthetics

The neuromuscular blocking effects of cisatracurium may be enhanced by local anesthetics.1,3

Magnesium Salts

The neuromuscular blocking effects of cisatracurium may be enhanced by magnesium salts.1,3,40 Caution is advised and a reduction in cisatracurium dosage may be necessary.40

Nondepolarizing Neuromuscular Blocking Agents

Potency and duration of nondepolarizing neuromuscular blocking agents may be altered by concurrent or prior administration of other nondepolarizing agents.31 In clinical studies, vecuronium, pancuronium, or atracurium was administered following various degrees of recovery from cisatracurium-induced neuromuscular blockade without any evidence of interaction.1

Procainamide

The neuromuscular blocking effects of cisatracurium may be enhanced by procainamide.1,3

Propofol

Propofol has no apparent effect on the duration of neuromuscular blockade induced by cisatracurium.1 No dosage adjustment of cisatracurium is required.1

Quinidine

The neuromuscular blocking effects of cisatracurium may be enhanced by quinidine.1,3

Succinylcholine

Cisatracurium has been used safely following various degrees of recovery from succinylcholine-induced neuromuscular blockade.1 Prior administration of succinylcholine may decrease the time to maximum neuromuscular blockade with cisatracurium by about 2 minutes.1 Prior administration of succinylcholine does not appear to alter the duration of blockade induced by intermittent injections of cisatracurium; prior administration resulted in no change or only a slight increase in cisatracurium infusion requirements.1

Description

Cisatracurium besylate is a nondepolarizing neuromuscular blocking agent that produces pharmacologic effects similar to those of other nondepolarizing neuromuscular blocking agents.1 (See Pharmacology in the Neuromuscular Blocking Agents General Statement 12:20.20.) Cisatracurium produces skeletal muscle relaxation by causing a decreased response to acetylcholine (ACh) at the myoneural (neuromuscular) junction of skeletal muscle.1,2 The drug exhibits a high affinity for ACh receptor sites and competitively blocks access of ACh to the motor end-plate of the myoneural junction, and may affect ACh release.1,2 Cisatracurium blocks the effects of both the small quantities of ACh that maintain muscle tone and the large quantities of ACh that produce voluntary skeletal muscle contraction.2 The drug does not alter the resting electrical potential of the motor end-plate or cause muscular contractions.2 The neuromuscular blocking potency of cisatracurium is approximately threefold that of atracurium.1,7,14 Cisatracurium exhibits minimal, if any, cardiovascular effects.1,3,16,18,20 The drug exhibits little histamine-releasing activity at usual therapeutic doses.1,5,11,14,17,19

Cisatracurium has an intermediate onset and duration of action.1,5,6,20 Cisatracurium is rapidly metabolized via Hofmann elimination (independent of the liver) to form a monoquaternary acrylate metabolite (which undergoes nonspecific plasma esterase hydrolysis and subsequent Hofmann elimination) and laudanosine (which is demethylated and glucuronidated).1,3,6,11,14,15,19,47 Both metabolites lack neuromuscular blocking activity; laudanosine may have CNS excitatory activity when present in large amounts.1,6,47 Cisatracurium is eliminated principally by Hofmann elimination (77-80%) and to lesser extent by renal and hepatic elimination (20%).1,6 Metabolites of the drug are eliminated principally by renal and hepatic elimination.1 The elimination half-life of cisatracurium is approximately 22-30 minutes.1,6,47

Advice to Patients

Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1

Importance of informing clinician of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses (e.g., cardiovascular disease, neuromuscular disease).1

Importance of informing patients of other important precautionary information.1 (See Cautions.)

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer's labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

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4. Society of Critical Care Medicine and American Society of Health-System Pharmacists. Sedation, analgesia, and neuromuscular blockade of the critically ill adult: revised clinical practice guidelines for 2002. Am J Health-Syst Pharm . 2002; 59:147-9. [PubMed 11826569]

5. Bryson HM, Faulds D. Cisatracurium besilate: a review of its pharmacology and clinical potential in anaesthetic practice. Drugs . 1997; 53:848-66. [PubMed 9129870]

6. Kisor DF, Schmith VD. Clinical pharmacokinetics of cisatracurium besilate. Clin Pharmacokinet . 1999; 36:27-40. [PubMed 9989341]

7. Mellinghoff H, Radbruch L, Diefenbach C et al. A comparison of cisatracurium and atracurium: onset of neuromuscular block after bolus injection and recovery after subsequent infusion. Anesth Analg . 1996; 83:1072-5. [PubMed 8895288]

8. Newman PJ, Quinn AC, Grounds RM et al. A comparison of cisatracurium (51W89) and atracurium by infusion in critically ill patients. Crit Care Med . 1997; 25:1139-42. [PubMed 9233738]

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