Cisatracurium (Nimbex) is a benzylisoquinolinium non-depolarizing neuromuscular blocking agent (NMBA) that works similar to rocuronium/vecuronium as a competitive nicotinic acetylcholine receptor (AChR) antagonist at the motor endplate.
Although it has a slower onset of action compared to succinylcholine and high-dose rocuronium making it less suited for rapid sequence inductions (RSI), cisatracurium is metabolized through Hofmann elimination – a process that occurs in the tissue and plasma INDEPENDENT of renal and hepatic function. This makes it ideal for patients with baseline organ impairment or those with evolving multiorgan pathology.
As an intensivist, I most commonly use cisatracurium infusions in patients with early, severe acute respiratory distress syndrome (ARDS) for better patient-ventilator synchrony when promoting lung protective ventilation strategies. As an anesthesiologist, I’ll use cisatracurium in patients with organ impairment (especially for shorter cases) although the advent of sugammadex makes aminosteroid NMJBs like rocuronium and vecuronium more attractive for a “cleaner” reversal.
Remember that cisatracurium is NOT reversed with sugammadex. This is an important consideration for the rare event in which a patient who initially received either rocuronium or vecuronium is reversed with a hefty dose of sugammadex and requires immediate RE-paralysis for reintubation. In this case, cisatracurium would be my “go to” paralytic since its efficacy would not be altered by circulating sugammadex.
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