AHFS Class:

12:20.20 Neuromuscular Blocking Agents

Generic Name

• Cisatracurium Besylate

Cisatracurium besylate is available as a solution in 5- and 10-mL vials containing cisatracurium besylate equivalent to cisatracurium 2 mg/mL.²⁸⁶⁸ The drug is also available as a solution in 20-mL vials containing cisatracurium besylate equivalent to cisatracurium 10 mg/mL intended for use in intensive care units only.²⁸⁶⁸ The pH is adjusted with benzenesulfonic acid.²⁸⁶⁸ The 2-mg/mL concentration in 10-mL vials also contains benzyl alcohol 0.9%.²⁸⁶⁸ The other dosage forms have no preservative and are for single use only.²⁸⁶⁸

pH

From 3.25 to 3.65.²⁸⁶⁸

Trade Name(s)

Nimbex

Cisatracurium besylate is administered intravenously only.²⁸⁶⁸ Both initial bolus doses and continuous intravenous infusion have been used.²⁸⁶⁸ Rates of administration depend on the drug concentration in the solution, desired dose, and patient weight.²⁸⁶⁸ Avoid contact with alkaline drugs during administration.²⁸⁶⁸

Cisatracurium besylate injection is a colorless to slightly yellow or greenish-yellow solution.²⁸⁶⁸ Intact vials of cisatracurium besylate should be stored at 2 to 8°C protected from light and freezing.²⁸⁶⁸ Potency losses of 5% per year occur under refrigeration.²⁸⁶⁸ However, at 25°C, potency losses increase to about 5% per month.²⁸⁶⁸ The manufacturer recommends that vials that have been warmed to room temperature be used within 21 days even if rerefrigerated.²⁸⁶⁸

In an independent study, cisatracurium besylate at cisatracurium concentrations of 2 mg/mL in 5- and 10-mL vials and 10 mg/mL in 20-mL vials was stored at 4 and 23°C both protected from light and exposed to fluorescent light. All the samples remained physically stable throughout the 90-day study period. Samples stored under refrigeration exhibited little or no drug loss in 90 days whether exposed to or protected from light. At 23°C, samples were stable through 45 days of storage with losses near 5 to 7% in most samples. However, most samples became unacceptable after 90 days of storage at 23°C, exhibiting losses of 9 to 14%.²¹¹⁶

pH Effects

The manufacturer indicates that cisatracurium besylate may not be compatible with barbiturates and other alkaline solutions having a pH greater than 8.5.²⁸⁶⁸

Syringes

In 2015, reports of decreased potency of certain drugs (e.g., cisatracurium besylate) stored in Becton Dickinson syringes for extended periods (i.e., exceeding 24 hours) were confirmed by the manufacturer of these syringes; the cause of this change was later identified to be the inclusion of an alternate rubber stopper in the plunger of certain product lots of syringes.³⁰²⁹; ³⁰³⁶; ³⁰³⁷; ³⁰³⁹; ³⁰⁴¹; ³⁰⁴² Decreased potency was not observed when the syringes were filled and used promptly.³⁰³⁷ Use of the alternate stopper was later discontinued and use of the primary stopper in such syringes was resumed; however, Becton Dickinson states that its general-use syringes are cleared by FDA for immediate use in fluid aspiration and injection and that such syringes, regardless of the stopper material, have not been cleared by FDA for use as a closed-container system.³³⁹¹

Cisatracurium besylate at a cisatracurium concentration of 2 mg/mL was repackaged in 3-mL plastic syringes (Becton Dickinson) and sealed with tip caps (Red Cap, Burron). The syringes were stored at 4 and 23°C both protected from light and exposed to fluorescent light. All of the samples remained physically stable throughout the 30-day study period. Little or no loss occurred when stored under refrigeration, whereas samples stored at 23°C exhibited 4 to 7% loss in 30 days.²¹¹⁶

Standardize 4 Safety

One or more standardized concentrations for this drug have been established through Standardize 4 Safety (S4S), a national patient safety initiative to reduce medication errors, especially during transitions of care. (See Standardize 4 Safety in Users Guide.) Recommendations developed to date through this initiative are available at www.ashp.org/pharmacy-practice/standardize-4-safety-initiative.

Table 1. Standardize 4 Safety Continuous IV Infusion Standard Concentrations for Cisatracurium³⁶³⁵; ³⁶³⁶

^aParalytics are recommended to be administered as straight drug. This provides consistency between operating room and the ICU, and eliminates potential compounding errors.^bThis is a concentration that differs from the package insert, therefore infusion-related calculations will differ from the prescribing information.

Solution Compatibility

Y-Site Injection Compatibility (1:1 Mixture)

For a list of references cited in the text of this monograph, search the monograph titled References.

ASHP^® Injectable Drug Information^TM. Selected Revisions December 5, 2024. © Copyright, 2024. American Society of Health-System Pharmacists^®, 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.