Pharmacology · Neuromuscular blockers
Cisatracurium !
An isomer of atracurium, more potent and without histamine release. Eliminated by Hofmann degradation, independent of liver and kidney; widely used in the ICU.
Updated 2026-11-01
Also called: Cisatracurium besilate
There is no structure with cisatracurium. The figure shows d-tubocurarine, another benzylisoquinoline, at the acetylcholine site of the Torpedo ray muscle-type nicotinic receptor.
Mechanism of action
Cisatracurium is one of the isomers of atracurium. It competes with acetylcholine for the nicotinic receptor of the motor end plate without activating it. It is more potent than the atracurium mixture and, at usual doses, releases no histamine. It breaks down mainly by Hofmann elimination in plasma, so recovery barely changes with renal or hepatic failure.
- Competes with acetylcholine at the nicotinic receptor
- Flaccid paralysis of intermediate duration
- No histamine release: stable haemodynamics
- Organ-independent Hofmann elimination
Pharmacokinetics
- Metabolism
- Hofmann elimination in plasma, forming laudanosine and other products.
- Elimination
- Predominantly organ-independent; the metabolites are cleared by kidney and liver and can accumulate if these fail.
Indications
- Tracheal intubation and muscle relaxation in surgery
- Facilitating mechanical ventilation in the ICU, including with renal or hepatic failure
Adverse effects
Common
- Bradycardia
- Hypotension
- Flushing
- Bronchospasm
- Rash
Contraindications
- Hypersensitivity to cisatracurium
- Multiple-dose vials with benzyl alcohol in infants under one month and low-birth-weight newborns
Key interactions
- Halogenated agents, aminoglycosides, magnesium, lithium
- Enhance the block.
- Chronic phenytoin or carbamazepine
- Shorten the duration of block.
- Alkaline solutions
- Incompatible in the same line.
What is monitored
- Train-of-four, especially with long infusions
- Ventilation and saturation
- Adequate sedation of the paralysed patient
Administration and safety
- Keep refrigerated; paralysing agent, stored apart and with warnings.
- Multiple-dose vials contain benzyl alcohol: consider the total load in infants.
- Do not mix with alkaline solutions in the same line.
Nursing care
- In the ICU: train-of-four to use the lowest dose and limit exposure to metabolites.
- Assess sedation and analgesia of the paralysed patient.
- Care for eyes, skin and repositioning.
- Watch for seizures in patients with renal or hepatic failure and prolonged use.
Pregnancy and breastfeeding
Data in pregnant women are too limited to establish a risk.
Test yourself
Think of the answer, then tap the question to see it.
How does cisatracurium differ from atracurium?
It is one of its isomers, more potent, and at usual doses it releases no histamine.
Why is cisatracurium useful in an ICU patient with renal and hepatic failure?
Its elimination is mainly by Hofmann degradation in plasma, independent of organs.
Which cisatracurium metabolite is a concern with long infusions?
Laudanosine, which causes seizures in animals and can accumulate if kidney or liver fail.
Related drugs
← Back to the class: Neuromuscular blockers
Educational content on how drugs work; not a prescribing guide and no substitute for a health professional's advice. No doses are given.
Sources: DailyMed - CISATRACURIUM BESYLATE injection, solution (DailyMed (U.S. National Library of Medicine), 2026); Goodman & Gilman's The Pharmacological Basis of Therapeutics, 14th ed., ch. 13 (McGraw Hill, 2023); ATCDDD - ATC/DDD Index (WHO Collaborating Centre for Drug Statistics Methodology, 2026).
Spotted a mistake?We are always improving for the community. Tell us what is wrong and our team will review it.Report a mistake
Representative model, for educational purposes only.