Cisatracurium

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sevodex1

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Just wanted to know if most centers out there use cisatracurium for ESRD patients , renal transplants, ESLD .
We do not have cis-atra available and use rocuronium for most of the above mentioned classes of patients. The literature suggests the elimination of rocuronium to be prolonged in renal failure and I have seen 2 cases of inadequate reversal despite allowing for adequate time and reversal dosing.
Wanted to get a feel for what people think...
 
We don't have cis on formulary either. It's pretty much all roc for us. Just decrease your dose up front - you can always add more.
 
We do have cisatracurium on formulary and it is often but not universally used for the renal failure patients, transplant, etc. but as others have stated, the less is more approach works just as fine with rocuronium. The caveat is NMB infusions-- cisatracurium is great for infusion titration in the appropriate circumstances.
 
Neuromuscular blocking agents in CRF


Rocuronium: elimination half-time increased by 37%. Both volume of distribution and plasma clearance are increased. That said, according to Miller, “the duration of action of single and repeated doses, though, is not significantly affected.

Vecuronium: elimination half-time increased by 24-56%. Vecuronium is primarily eliminated via hepatic mechanisms, however, its elimination half-life is still increased in patients with renal failure. Duration of action appears to be both longer and more variable in patients with renal failure. Note that 3-desacetylvecuronium, the principal metabolite of vecuronium, has 80% of the neuromuscular blocking activity of its parent compound and may prolong paralysis.

Pancuronium: elimination half-time increased by 97%. Duration of action prolonged.

Atracurium: duration of action unaffected by renal failure. Hofmann elimination and ester hydrolysis account for 50% of total clearance. Elimination half-life of neurotoxic metabolite laudanosine increases in renal failure, although this may not be clinically relevant

cis-Atracurium: duration of action is not prolonged. Hofmann elimination accounts for 77% of total clearance, renal excretion accounts for 16%

Paralytics in Setting of Renal Failure

  • Rocuronium: t 1/2 increased 37%, may not translate into increased duration
  • Vecuronium: t 1/2 increased 24-56%, duration longer and more variable
  • Pancuronium: t 1/2 increased 97%, prolonged duration of action
 
In my main hospital for fellowship, cisatracurium is available only to Anesthesiology in the ORs. For some reason for ICU use, we have Atracurium. Until I started fellowship here, I didn't even know atracurium still existed in the US. I thought it went the halothane path.
 
I use dis in these pts when the case is short. I use roc when it is longer.
 
Noyac said:
I use dis in these pts when the case is short. I use roc when it is longer.
Click to expand...

Any particular dis you like to use? Do you shake your head gently when they mention their BMI, or comment on their breath during the airway exam?

(Sorry, had to say it)
 
norwood said:
Any particular dis you like to use? Do you shake your head gently when they mention their BMI, or comment on their breath during the airway exam?

(Sorry, had to say it)
Click to expand...
Yep I like to talk **** about their mother.
 
I use cis almost exclusively for everything....love the drug.

Call me crazy, but I like predictable drugs. I know it is fun to use roc and wonder if this is the guy that chews it all up in 20 minutes, or will this be the guy that isn't reversable in 2 hours after a single dose...i know fun...but I like fun in other ways.
 
epidural man said:
I use cis almost exclusively for everything....love the drug.

Call me crazy, but I like predictable drugs. I know it is fun to use roc and wonder if this is the guy that chews it all up in 20 minutes, or will this be the guy that isn't reversable in 2 hours after a single dose...i know fun...but I like fun in other ways.
Click to expand...
OK ... you're crazy? 🙂 Spending that money when something cheap like roc or vec is just fine for almost all patients is silly. Use less roc maybe?

Roc is definitely less predictable than vec or cis, but it's not really unpredictable. Just don't slam in 0.6 mg/kg for a case that could be short.
 
pgg said:
OK ... you're crazy? 🙂 Spending that money when something cheap like roc or vec is just fine for almost all patients is silly. Use less roc maybe?

Roc is definitely less predictable than vec or cis, but it's not really unpredictable. Just don't slam in 0.6 mg/kg for a case that could be short.
Click to expand...
I sent a comparison to the residents a year or two ago comparing prices to cis and roc. It turns out - dose for dose, cis isn't more expensive. I'll try to find the comparison.

Even if it is more expensive, it is by about $2.
 
epidural man said:
I sent a comparison to the residents a year or two ago comparing prices to cis and roc. It turns out - dose for dose, cis isn't more expensive. I'll try to find the comparison.

Even if it is more expensive, it is by about $2.
Click to expand...
Didn't know that, thought it was still a lot more expensive. I'll have to ask our pharmacy what they pay ...
 
We have cis. I use it, but not all that often. I use it for patients with acute or chronic kidney disease, most commonly that's for kidney transplant, but also for your ICU players with AKI, vasculopaths with metastable CKD stage 3, etc. I suppose I would use it in someone with true liver failure, acute or chronic as well, but those patients are far less common.

Having inherited a kidney transplant where a patient got 1mg/kg rocuronium at induction...and then was allowed to become hypothermic to 35C...and then took 120 minutes for even the faintest twitch to be appreciable, I became even more wary of roc's unpredictable and long(er) duration than before.
 
fakin' the funk said:
We have cis. I use it, but not all that often. I use it for patients with acute or chronic kidney disease, most commonly that's for kidney transplant, but also for your ICU players with AKI, vasculopaths with metastable CKD stage 3, etc. I suppose I would use it in someone with true liver failure, acute or chronic as well, but those patients are far less common.

Having inherited a kidney transplant where a patient got 1mg/kg rocuronium at induction...and then was allowed to become hypothermic to 35C...and then took 120 minutes for even the faintest twitch to be appreciable, I became even more wary of roc's unpredictable and long(er) duration than before.
Click to expand...
:eyebrow: Why on earth would anyone use 1 mg/kg for induction? That's more than triple the ED95. Was there an indication for RSI here?

I'm just saying, I don't think you can fairly blame rocuronium for an absurd dose and then a mismanaged anesthetic ...
 
pgg said:
:eyebrow: Why on earth would anyone use 1 mg/kg for induction? That's more than triple the ED95. Was there an indication for RSI here?

I'm just saying, I don't think you can fairly blame rocuronium for an absurd dose and then a mismanaged anesthetic ...
Click to expand...
I concur.

Most people don't realize that muscle relaxant doses are way too high for what's really needed. As in one does not need 1 mg/kg of sux, or 0.6 mg/kg of roc for intubation. Unless doing RSI (or longer cases - for roc).

And if one thinks that roc is too unpredictable, just use vec. Because roc needs to be kept in the fridge, many times it will lose some of its potency when left in the cart for days.

On the other hand, I think cisatracurium is the perfect choice in ESRD. ESLD patients tend to get mostly just liver transplants, which are so long anyway that I never bothered to use cis, just titrated roc/vec carefully.
 
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I am a big fan of cisatracurium. To me, it seems like it is the "purest" of relaxants. Very few side effects, although obviously not good for RSI.

When I do long cases, with a surgeon that I know will complain constantly about relaxation, I like to use it as an infusion. It is my go-to-relaxant for liver transplants because of the obvious liver dysfunction that may occur. I avoid atracurium in liver transplants because if a patient becomes hypotensive, you will always ask yourself "Is it the histamine release?" With cisatracurium, you don't wonder if it is causing the hypotension.

A few months ago, I was using cisatracurium in a ESRD patient for abdominal washout of infected ventral hernia repair. My pharmacy is hit or miss if they have it, and I was happy to find that the pharmacy did have it. When they do have it, it is 10ml bottle of 2mg/mL. So I pick it up, notice that its not my usual looking bottle of cisatracurium, bring it to the OR, draw it up, only to find that it is not my usual volume of 10mL (it was a 20mL bottle). I think nothing of it because, like I said, the pharmacy is hit or miss and I assumed they had to get it from another distributor/manufacturer. I give the 0.15mg/kg intubating dose of cistracurium. 15 mintues later, the surgeon does the obligatory "Is the patient relaxed?" I check, 0/4 twitches. The surgery proceeds and as we get toward the end, still 0/4 twitches. I assumed that twitches would be back soon. It turns out that the pharmacy gave me the concentrated cisatracurium (10mg/ml) that is supposed to be diluted and is only supposed to be used in the ICU at my institution. It was an M&M a few weeks later. Patient woke up 30 minutes after surgery was supposed to end and did fine. Neither me nor my attending knew that a 10mg/mL concentration was even available. I learned my lesson.
 
I don't much like cis because of the slow onset. You lose style points when patients move, even a little, during intubation. An ED95 of roc comes on much faster than an ED95 of cis.

I use it most often for elderly folks, if they happen to be having a short procedure that requires relaxation.

For short ESRD cases I'll use cis, otherwise roc is fine.
 
mm2938 said:
So I pick it up, notice that its not my usual looking bottle of cisatracurium, bring it to the OR, draw it up, only to find that it is not my usual volume of 10mL (it was a 20mL bottle). I think nothing of it because, like I said, the pharmacy is hit or miss and I assumed they had to get it from another distributor/manufacturer. I give the 0.15mg/kg intubating dose of cistracurium. 15 mintues later, the surgeon does the obligatory "Is the patient relaxed?" I check, 0/4 twitches. The surgery proceeds and as we get toward the end, still 0/4 twitches. I assumed that twitches would be back soon. It turns out that the pharmacy gave me the concentrated cisatracurium (10mg/ml) that is supposed to be diluted and is only supposed to be used in the ICU at my institution. It was an M&M a few weeks later. Patient woke up 30 minutes after surgery was supposed to end and did fine. Neither me nor my attending knew that a 10mg/mL concentration was even available. I learned my lesson.
Click to expand...

This is a good lesson and reminder to everyone. We've all gotten comfortable in our practice settings. We know the layout of the drug carts, concentrations of each drug, and volumes of every last vial. And though I can't speak for everyone, I would venture to guess that everyone at one time or another has given a drug without reading the entire label (myself included). With the prevalence of SALADs (Sound-Alike, Look-Alike Drugs) in our carts, drugs can easily be mixed up, and though you think you're giving 4mg of ondansetron, you just pushed 20 units of vasopressin into the patient. Though I have gotten better about it, I need to continue making a dedicated effort to read the entire vial of every drug before I administer it, regardless of how many thousands of times I have given it. This becomes especially important if you move to a new practice environment (eg: new hospital, new out of OR site, or new drug vial that you are presented with). It takes 2 seconds to reconfirm the drug, helps prevents never events, and it keeps our patients safe.
 
My pharmacy changes suppliers of drugs so often and the labels and caps change as well. I'm afraid all the time of drug swaps and obsessively read the contents. There have been many incidents of the pharmacy or previous person putting the meds in the drawer incorrectly as well.
 
epidural man said:
I use cis almost exclusively for everything....love the drug.

Call me crazy, but I like predictable drugs. I know it is fun to use roc and wonder if this is the guy that chews it all up in 20 minutes, or will this be the guy that isn't reversable in 2 hours after a single dose...i know fun...but I like fun in other ways.
Click to expand...

I like nimbex too. I'll use roc for initial
paralytic in longer cases but we routinely have both in our trays. I like the predictability as well. Have seen problems in pacu with roc on shorter cases.
 
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