Intravenous Facilitate endotracheal intubation, Muscle relaxant in general anaesthesia
Adult: Initially, 0.15-0.2 mg/kg via IV inj over 5-10 seconds. Maintenance of neuromuscular block: 0.03 mg/kg via IV inj over 5-10 seconds (each dose provides approx 20 minutes additional block during opioid or propofol anaesthesia). Alternatively, the maintenance dose may also be given via continuous IV infusion at an initial rate of 0.18 mg/kg/hour (3 mcg/kg/min), followed by an infusion rate of 0.06-0.12 mg/kg/hour (1-2 mcg/kg/min) after the primary stabilisation period. Infusion rates depend on the concentration of infusion solution, desired degree of neuromuscular block and patient's weight. All doses must be individualised based on the procedure, concurrent drugs given and the patient's response. Dosage recommendations may vary between countries (refer to specific local guidelines). Child: 1 month to <2 years Initially, 0.15 mg/kg via IV inj over 5-10 seconds. 2-12 years Initially, 0.1-0.15 mg/kg via IV inj over 5-10 seconds. Maintenance of neuromuscular block: 0.02 mg/kg via IV inj over 5-10 seconds (each dose provides approx 9 minutes additional block during halothane anaesthesia). Alternatively, the maintenance dose may also be given via continuous IV infusion at an initial rate of 0.18 mg/kg/hour (3 mcg/kg/min), followed by an infusion rate of 0.06-0.12 mg/kg/hour (1-2 mcg/kg/min) after primary stabilisation period. Infusion rates depend on the concentration of infusion solution, desired degree of neuromuscular block and patient's weight. All doses must be individualised based on the procedure, concurrent drugs given and the patient's response. Dosage recommendations may vary between countries (refer to specific local guidelines).
Intravenous Facilitate mechanical ventilation in intensive care
Adult: Initial rate of 0.18 mg/kg/hour (3 mcg/kg/min) via continuous IV infusion, then titrated based on patient response and neuromuscular monitoring. Usual range of infusion rate: 0.03-0.6 mg/kg/hour (0.5-10.2 mcg/kg/min). Following neuromuscular recovery, re-administration of IV inj doses may be needed in certain cases to re-establish neuromuscular blockade before starting the continuous infusion. All doses must be individualised based on the procedure, concurrent drugs given and the patient's response. Dosage recommendations may vary between countries (refer to specific local guidelines).
What are the brands available for Cisatracurium besilate in Malaysia?
Obese patients: Calculate the dose based on the ideal body weight.
Reconstitution
IV infusion: Dilute with dextrose 5% in water, NaCl 0.9%, and dextrose 5% in NaCl 0.9% solution to a concentration of 0.1 mg/mL. Recommendations for dilution and final concentration may vary among individual products and countries (refer to detailed product guidelines).
Incompatibility
Incompatible with propofol emulsion, ketorolac trometamol, alkaline solutions (e.g. thiopental sodium) and lactated Ringer's solution.
Contraindications
Hypersensitivity.
Special Precautions
Patient with history of anaphylactic reactions to other neuromuscular blockers; burn injury; conditions that may increase neuromuscular blockade (e.g. electrolyte abnormalities [e.g. hypokalaemia, hypocalcaemia, hypermagnesaemia], dehydration, carcinomatosis, metabolic or respiratory acidosis, neuromuscular diseases, Eaton-Lambert syndrome, myasthenia gravis); conditions that may antagonise neuromuscular blockade (e.g. respiratory alkalosis, hypercalcaemia, demyelinating lesions, peripheral neuropathies, denervation, muscle trauma); hemiparesis or paraparesis; pulmonary disease, including asthma. Obese and immobilised patients. Hypothermia may slow down the Hofmann elimination of cisatracurium besilate, resulting in a prolonged duration of paralysis. Not recommended for rapid sequence endotracheal intubation due to its intermediate onset of action. Children and elderly. Pregnancy and lactation.
Adverse Reactions
Significant: Bradycardia, residual paralysis; increased risk of seizures. Musculoskeletal and connective tissue disorders: Myopathy, muscle weakness. Respiratory, thoracic and mediastinal disorders: Bronchospasm. Skin and subcutaneous tissue disorders: Rash. Vascular disorders: Hypotension, flushing. Potentially Fatal: Severe hypersensitivity reactions, including anaphylaxis.
Monitoring Parameters
Monitor vital signs (e.g. heart rate, blood pressure, respiratory rate) and the degree of muscle paralysis (e.g. evidence of spontaneous movement, ventilator asynchrony, shivering, use of peripheral nerve stimulator).
Overdosage
Symptoms: Extended muscle paralysis and its effects.
Management: Symptomatic and supportive treatment. Maintain pulmonary ventilation and arterial oxygenation until adequate spontaneous breathing is restored. For reversal of neuromuscular block, may consider the administration of anti-cholinesterase agents (e.g. neostigmine, edrophonium) once evidence of spontaneous recovery is present.
Drug Interactions
May potentiate the neuromuscular blocking effect with other non-depolarising neuromuscular blockers, ketamine, anaesthetic agents (e.g. halothane, enflurane, isoflurane), aminoglycosides, polymyxins, tetracyclines, lincomycin, clindamycin, calcium channel blockers, antiarrhythmic drugs (e.g. procainamide, quinidine), diuretics (e.g. furosemide), magnesium salts, and lithium salts. May reduce neuromuscular blocking effect with prior chronic administration of phenytoin or carbamazepine. May result in prolonged and complex neuromuscular block with suxamethonium. May lead to shortened duration of action and reduced magnitude of neuromuscular blockade with donepezil.
Action
Description: Overview: Cisatracurium besilate is an intermediate-acting, benzylisoquinolone non-depolarising neuromuscular blocker. Mechanism of Action: Cisatracurium besilate competitively binds to cholinergic receptors on the motor end-plate of the myoneural junction to antagonise the action of acetylcholine, resulting in neuromuscular transmission blockade. Pharmacodynamics: Cisatracurium besilate produces neuromuscular blockade at a predictable sequence. Paralysis begins with muscles responsible for fine movements (e.g. eyes, face, neck), then progresses to the muscles of the limbs, chest, abdomen, and the diaphragm. Recovery of muscle tone occurs in reverse order. In adults receiving opioid/nitrous oxide/oxygen anaesthesia, the average dose required to produce 95% suppression of adductor pollicis muscle twitch response to ulnar stimulation is approx 0.05 mg/kg. Repeated administration of maintenance doses via IV inj or continuous infusion for up to 3 hours was not associated with cumulative neuromuscular blocking effect or tachyphylaxis development.
In healthy adults or patients with serious CV disease, cisatracurium besilate had no dose-related effects on mean arterial pressure (MAP) or heart rate (HR) after receiving doses ranging from 0.1-0.4 mg/kg via inj over 5-10 seconds. In children aged 2-12 years who received either halothane/nitrous oxide/oxygen or opioid/nitrous oxide/oxygen anaesthesia, no clinically significant changes in MAP or HR were demonstrated after receiving doses up to 0.1 mg/kg via inj over 5-10 seconds. Cisatracurium besilate appears to have little histamine-releasing properties at usual therapeutic doses. Onset: 2-3 minutes (dose-dependent). Duration: Approx 35-45 minutes (dose-dependent). Pharmacokinetics: Distribution: Crosses the placenta (laudanosine). Metabolism: Undergoes rapid nonenzymatic degradation via Hofmann elimination to form laudanosine and monoquaternary acrylate metabolite. The monoquaternary acrylate metabolite is further metabolised via hydrolysis by non-specific plasma esterases. Excretion: Mainly via urine (95%; <10% as unchanged drug); faeces (4%). Elimination half-life: 22-29 minutes.
Chemical Structure
Cisatracurium besilate Source: National Center for Biotechnology Information. PubChem Compound Summary for CID 62886, Cisatracurium Besylate. https://pubchem.ncbi.nlm.nih.gov/compound/Cisatracurium-Besylate. Accessed Feb. 25, 2026.
Storage
Intact vial: Store between 2-8°C. Do not freeze. Protect from light. Diluted solution for IV infusion (using NaCl 0.9%, dextrose 5% in water, or dextrose 5% in NaCl 0.9%) at 0.1 mg/mL concentration: Store between 2-8°C or at 25°C for up to 24 hours. Storage and stability recommendations may vary among individual products or between countries (refer to specific product guidelines).
M03AC11 - cisatracurium ; Belongs to the class of other quaternary ammonium-containing agents used as peripherally-acting muscle relaxants.
References
Brayfield A, Cadart C (eds). Atracurium Besilate. Martindale: The Complete Drug Reference [online]. London. Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 13/11/2025.Cisatracurium Besilate 5 mg/mL Solution for Injection/Infusion (Dawa Limited). MHRA. https://products.mhra.gov.uk. Accessed 13/11/2025.Cisatracurium Besylate 5 mL, 20 mL Injection (Hikma Pharmaceuticals USA Inc.). DailyMed. Source: U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed. Accessed 13/11/2025.Cisatracurium Besylate. UpToDate Lexidrug, AHFS DI (Adult and Pediatric) Online. American Society of Health-System Pharmacists, Inc. Waltham, MA. UpToDate, Inc. https://online.lexi.com. Accessed 13/11/2025.Cisatracurium Kabi 2 mg/mL Solution for Injection or Infusion (Fresenius Kabi Malaysia Sdn Bhd). National Pharmaceutical Regulatory Agency - Ministry of Health Malaysia. https://www.npra.gov.my. Accessed 13/11/2025.Cisatracurium. Gold Standard Drug Database in ClinicalKey [online]. Elsevier Inc. https://www.clinicalkey.com. Accessed 18/11/2025.Cisatracurium. UpToDate Lexidrug, Lexi-Drugs Multinational Online. Waltham, MA. UpToDate, Inc. https://online.lexi.com. Accessed 13/11/2025.Joint Formulary Committee. Cisatracurium. British National Formulary [online]. London. BMJ Group and Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 13/11/2025.Paediatric Formulary Committee. Cisatracurium. BNF for Children [online]. London. BMJ Group, Pharmaceutical Press, and RCPCH Publications. https://www.medicinescomplete.com. Accessed 24/02/2026.
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