Cisatracurium

Neuromuscular blockade: IV (not to be used IM): Operating room administration: Intubating dose: 0.15-0.2 mg/kg as components of propofol/nitrous oxide/oxygen induction-intubation technique. (Note: May produce generally good or excellent conditions for tracheal intubation in 1.5-2 minutes with clinically effective duration of action during propofol anesthesia of 55-61 minutes.) Initial dose after succinylcholine for intubation: 0.1 mg/kg; maintenance dose: 0.03 mg/kg 40-60 minutes after initial dose, then at ~20-minute intervals based on clinical criteria. Continuous infusion: After an initial bolus, a diluted solution can be given by continuous infusion for maintenance of neuromuscular blockade during extended surgery; adjust the rate of administration according to the patient's response as determined by peripheral nerve stimulation. An initial infusion rate of 3 mcg/kg/minute (0.18 mg/kg/hour) may be required to rapidly counteract the spontaneous recovery of neuromuscular function; thereafter, a rate of 1-2 mcg/kg/minute (0.06-0.12 mg/kg/hour) should be adequate to maintain continuous neuromuscular block in the 89% to 99% range in most pediatric and adult patients. Consider reduction of the infusion rate by 30% to 40% when administering during stable isoflurane, enflurane, sevoflurane, or desflurane anesthesia. Spontaneous recovery from neuromuscular blockade following discontinuation of infusion of cisatracurium may be expected to proceed at a rate comparable to that following single bolus administration. Intensive care unit paralysis (eg, facilitate mechanical ventilation) in selected adequately sedated patients: Manufacturer's labeling: 0.15 to 0.2 mg/kg loading dose; at initial signs of recovery from bolus dose, begin the infusion at a dose of 3 mcg/kg/minute (0.18 mg/kg/hour) and adjust rate accordingly (follow the principles for infusion in the operating room); dosage ranges of 0.5 to 10 mcg/kg/minute (0.03 to 0.6 mg/kg/hour) have been reported. If patient is allowed to recover from neuromuscular blockade, readministration of a bolus dose may be necessary to quickly re-establish neuromuscular block prior to reinstituting the infusion. Alternative recommendations: 0.1 to 0.2 mg/kg loading dose followed immediately by an infusion of 1 to 3 mcg/kg/minute (0.06 to 0.18 mg/kg/hour); adjust rate accordingly (Greenberg 2013) or in patients with acute respiratory distress syndrome, may administer a non-weight based dosing regimen of 15 mg (loading dose) followed immediately by 37.5 mg/hour for 48 hours; may administer 20 mg rapid boluses during infusion based on clinical parameters (eg, end-inspiratory plateau pressure remains >32 cm H2O) (Papazian 2010).