Classification: non-depolarizing neuromuscular blocker; skeletal muscle relaxant
  • used to facilitate mechanical ventilation reduces airway resistance/pressures reduces metabolic rate and O2 consumption used in the management of tetanus
  • safe for use in patients with malignant hyperthermia

may be used to stop muscle activity during a seizure but has no anticonvulsant properties

Table 1. Indications and Dosing of Neuromuscular Blockers (NMB’s)

Indications Recommended NMB Dose
Single dose for procedure, mechanical ventilation or hypothermia Rocuronium 0.6-1.2 mg/kg
(round to nearest 10 mg)

Continuous infusion for hypothermia or mechanical ventilation

Rocuronium 0.5-0.7 mg/kg/hr

Continuous infusion for hypothermia or mechanical ventilation with renal or hepatic dysfunction. 


0.1 mg/kg bolus, then 5-10 mg/hour

(0.03 - 0.6 mg/kg/hour)


  • IV Direct:
    • 0.15-0.2mg/kg IV
  • IV Infusion:
    • 0.03-0.6 mg/kg/hr (equal to 0.5-10  mcg/kg/min)

ARDS NET Protocol:

Cisatracurium 15 mg IV bolus, then 37.5 mg/hour IV continuous
infusion for 48 hours.  Do not titrate.


  • dose reduction is not required in either hepatic or renal insufficiency; dose requirements may be increased in patients with severe hepatic disease.
Administration: IV Infusion:
2mg/mL (undiluted) in syringe or viaflex bag 
  • mechanical ventilation must be increased to provide full support prior to administration
Adverse Effects:
  • bradycardia or tachycardia
  • hypertension or hypotension
  • bronchospasm
  • anaphylaxis
  • hypothermia
  • corneal ulceration
  • excessive salivation
  • in history of myasthenia gravis, Eaton-Lambert syndrome, amyotrophic lateral sclerosis or other neuromuscular disease; respiratory acidosis; hypokalemia; asthma; anaphylactic reactions 
  • anticholinesterase agents, e.g. neostigmine
Drug Interactions:
  • cisatracurium + aminoglycosides = increased neuromuscular blocking effect
  • cisatracurium + steroids = possible increased risk of myopathy
  • cisatracurium + anticonvulsants = possible decreased effect of cisatracurium
Monitoring Therapy:
  • continuous heart rater and rhythym
  • continuous blood pressure
  • continuous End Tital Carbon Dioxide monitoring
  • continuous oxygen saturation
  • ventilator parameters and monitor alarms
  • chest sounds
  • blood gases
  • electrolytes
  • temperature
  • eyes - keep moist and closed
  • skin/limb support
  • Routine use of Train of four (T.O.F) is no longer required

  • Has no CNS effects, therefore, consider patients able to hear and comprehend.
  • Has no analgesic or sedative properties; patients require continuous analgesic and sedative administration.
  • Pupils and GI tract are not affected.
Adult Critical Care Protocol:
  • Patient must be fully ventilated on a controlled mode before administration of any dose of neuromuscular blockade.
  • May be administered IV direct or by IV infusion by a nurse in Adult Critical Care providing that the patient is receiving full mechanical ventilation.
  • A nurse in Adult Critical Care may administer the initial dose.
  • Administration of anaesthetic dosing of analgesics and sedatives must PRECEED initiation of neuromuscular blocking agents.
  • A continuous infusion of analgesics and sedatives must be administered with an infusion of neuromuscular blocking agents.
  • Continuous infusion must be administered via an infusion pump.
  • May be titrated by a nurse in Adult Critical Care.
  • Patient requires placement of an arterial line to monitor BP.
  • Patient requires End Tidal CO2 monitoring.
  • Continuous infusions must be administered by infusion pump device and the pump library must be enabled.
  • A bedside sign alerting staff of neuromuscular blocker use must be displayed

Lynne Kelly, Pharmacist, CCTC
Brenda Morgan, Clinical Nurse Specialist, CCTC
Last Update: February 1, 2022