Nimbex

cisatracurium

Nimbex

Indications

Action

Pharmacokinetics

Time/action profile

Contraindications/Precautions

Adverse Reactions/Side Effects

Respiratory

• bronchospasm

Dermatologic

• rash

Miscellaneous

• allergic reactions including anaphylaxis (life-threatening)

Interactions

Drug-Drug interaction

Route/Dosage

Availability (generic available)

Nursing implications

Nursing assessment

• Assess respiratory status continuously throughout therapy with cisatracurium. Use only to facilitate intubation or in patients already intubated.
• Monitor neuromuscular response with a peripheral nerve stimulator intraoperatively. Paralysis is initially selective and usually occurs sequentially in the following muscles: levator muscles of eyelids, muscles of mastication, limb muscles, abdominal muscles, muscles of the glottis, intercostal muscles, and the diaphragm. Recovery of muscle function usually occurs in reverse order.
• Monitor ECG, heart rate, and BP throughout administration.
• Observe the patient for residual muscle weakness and respiratory distress during the recovery period.
• Monitor infusion site frequently. If signs of tissue irritation or extravasation occur, discontinue and restart in another vein.
If overdose occurs, use peripheral nerve stimulator to determine the degree of neuromuscular blockade. Maintain airway patency and ventilation until recovery of normal respirations occurs.
• Administration of anticholinesterase agents (neostigmine, pyridostigmine) may be used to antagonize the action of cisatracurium once the patient has demonstrated some spontaneous recovery from neuromuscular block. Atropine is usually administered prior to or concurrently with anticholinesterase agents to counteract the muscarinic effects.
• Administration of fluids and vasopressors may be necessary to treat severe hypotension or shock.

Potential Nursing Diagnoses

Implementation

• high alert: Unplanned administration of a neuromuscular blocking agent instead of administration of the intended medication or administration of a neuromuscular blocking agent in the absence of ventilatory support has resulted in serious harm and death. Confusing similarities in packaging and insufficiently controlled access to these medications are often implicated in these medication errors.
• Dose is titrated to patient response.
  • Cistracurium hasno effect on consciousness or pain threshold. Adequate anesthesia/analgesia should always be used when neuromuscular blocking agents are used as an adjunct to surgical procedures or when painful procedures are performed. Benzodiazepines and/or analgesics should be administered concurrently when prolonged neuromuscular blocker therapy is used for ventilator patients, because patient is awake and able to feel all sensations.
  • Not recommended for rapid sequence endotracheal intubation due to intermediate onset of action.
  • If eyes remain open throughout prolonged administration, protect corneas with artificial tears.

• Intravenous Administration

• May be administered undiluted.
• Rate: Administer initial IV dose as a bolus over 1 min.
• Intermittent Infusion: Maintenance dose is usually required 40–60min following initial dose.
  • Diluent: D5W, 0.9% NaCl, D5/0.9% NaCl., or D5/LR. Solutions diluted to 0.1 mg/mL in D5/W, 0.9% NaCl, or D5/0.9% NaCl may be stored at room temperature or in refrigeration for 24 hrs. Solutions dilutes 0.1–0.2 mg/ml in D5/LR may be stored for up to 24 hrs in refrigerator.
• Continuous Infusion: Maintenance dose is administered by infusion..
• Rate: 3 mcg/kg/min intially, then 1–2 mcg/kg/min. Titrate according to patient response.
• Y-Site Compatibility: alemtuzumab, alfentanil, amikacin, aminocaproic acid, amiodarone, amphotericin B lipid complex, anidulafungin, argatroban, arsenic trioxide, azithromycin, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium gluconate, carboplatin, carmustine, caspofungin, ceftaroline, cefotaxime, ceftriaxone, chlorpromazine, ciprofloxacin, cisplatin, clindamycin, cyclophosphamide, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmeditomidine, dexrazoxane, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel, dopamine, doxorubicin hydrochloride liposome, doxycycline, enalaprilat, epinephrine, epirubicin, eptifibatide, ertapenem, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, fluconazole, fludarabine, fluorouracil, foscarnet, gemcitabine, gentamicin, granisetron, haloperidol, hetastarch, hydrocortisone sodium succinate, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, irinotecan, isoproterenol, ketorolac, leucovorin, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, methotrexate, metoclopramide, metronidazole, midazolam, milrinone, minocycline, mitoxantrone, morphine, mycophenolate, nafcillin, nalbuphine, nesiritide, nicardipine, nitroglycerin, norepinephrine, octreotide, ondansetron, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, papaverine, pemetrexed, phenylephrine, potassium acetate, potassium chloride, procainamide, prochlorperazine, promethazine, quinupristin/dalfopristin, ranitidine, remifentanil, sodium acetate, sufentanil, tacrolimus, teniposide, theophylline, thiotepa, tigecycline, tirofiban, tobramycin, tolazoline, vancomycin, vasopressin, vinblastine, vincristine, vinorelbine, voriconazole, zidovudine, zolendronic acid
• Y-Site Incompatibility: amphotericin B cholesteryl, cefoperazone, micafungin, pantoprazole

Patient/Family Teaching

• Explain all procedures to patient receiving cisatracurium therapy without general anesthesia, because consciousness is not affected by cisatracurium alone.
• Reassure patient that communication abilities will return as the medication wears off.

Evaluation/Desired Outcomes

• Adequate suppression of the twitch response when tested with peripheral nerve stimulation and subsequent muscle paralysis.
• Improved compliance during mechanical ventilation.