Indications for NIMBEX:
As an adjunct to general anesthesia to facilitate tracheal intubation in adults and children 1 month to 12yrs of age. To provide skeletal muscle relaxation during surgery or mechanical ventilation in the ICU in adults, or during surgery via infusion in children ≥2yrs.
Limitations of Use:
Not for rapid sequence endotracheal intubation.
See full labeling. Individualize. IV bolus: Initial dose: 0.15mg/kg or 0.2mg/kg (up to 0.4mg/kg have been used; with neuromuscular disease: max 0.02mg/kg); duration of action with propofol anesthesia: 0.15mg/kg: approx. 55mins, 0.2mg/kg: approx. 61mins. Maintenance: 0.03mg/kg; generally required 40–50mins after initial dose of 0.15mg/kg or 50–60mins after initial dose of 0.2mg/kg. No adjustment in initial maintenance dose necessary when cisatracurium is given shortly after initiation of volatile agents or when used with propofol anesthesia. Continuous infusion: may be given after initial bolus dose to patients with spontaneous recovery during extended surgical procedures or extended need for mechanical ventilation in the ICU. Surgery: infuse at a rate of 3mcg/kg/min initially, then reduce to 1–2mcg/kg/min; titrate based on level of blockade. Under isoflurane/enflurane anesthesia for ≥30mins: reduce rate by 30–40%. CABG: consider reducing rate; see full labeling. ICU: 3mcg/kg/min; titrate based on level of blockade.
<1month: not established. See full labeling. Individualize. IV bolus: 1–23mos: initial dose: 0.15mg/kg given over 5–10secs; duration of action with opioid/nitrous oxide/oxygen anesthesia: approx. 43mins. 2–12yrs: initial doses: 0.1–0.15mg/kg given over 5–10secs; duration of action with opioid/nitrous oxide/oxygen anesthesia: 0.1mg/kg: approx. 28mins, 0.15mg/kg: approx. 36mins. Continuous infusion: may be given after initial bolus dose to patients with spontaneous recovery during extended surgical procedures. ≥2yrs: infuse at a rate of 3mcg/kg/min initially, then reduce to 1–2mcg/kg/min; titrate based on level of blockade. Under isoflurane/enflurane anesthesia for ≥30mins: reduce rate by 30–40%.
Neonates <1 month of age, low birth-weight infants (10mL vial contains benzyl alcohol).
To be administered under the supervision of experienced clinicians. Have intubation, artificial respiration, oxygen therapy and reversal agents available. Risk of residual paralysis esp. in patients with neuromuscular diseases (eg, myasthenia gravis, myasthenic syndrome), carcinomatosis; use lower max initial bolus (see Adults). Previous anaphylactic reaction to other neuromuscular blockers. Acid-base and/or serum electrolyte abnormalities. Be prepared to recognize and treat malignant hyperthermia. ICU: monitor neuromuscular function; if no response elicited, discontinue until response returns. Burn patients: consider dose increases. Patients with hemiparesis or paraparesis; perform neuromuscular monitoring on non-paretic limb. Renal or hepatic impairment: increased risk of seizures. ESRD, elderly: consider extending interval between administration and intubation by ≥1min. Labor & delivery. Pregnancy. Nursing mothers.
Neuromuscular blocker (nondepolarizing).
May be potentiated by inhalational anesthetics (eg, isoflurane, enflurane), antibiotics (eg, aminoglycosides, tetracyclines, bacitracin, polymyxins, lincomycin, clindamycin, colistin, sodium colistemethate), magnesium salts, lithium, local anesthetics, procainamide, quinidine. May be antagonized by chronically administered phenytoin or carbamazepine.
Bradycardia, hypotension, flushing, bronchospasm, rash; hypersensitivity reactions.
Generic Drug Availability:
Single-dose vial (2mg/mL)—5mL; Single-dose vial (10mg/mL)—20mL; Multi-dose vial (2mg/mL)—10mL (contains benzyl alcohol)