The use of succinylcholine prior to NIMBEX may decrease the time to onset of maximum neuromuscular blockade but has no effect on the duration.Because MH can develop in the absence of established triggering agents, the clinician should be prepared to recognize and treat MH in any patient undergoing general anesthesia. NIMBEX has not been studied in patients susceptible to malignant hyperthermia (MH).Use peripheral nerve stimulation and monitor clinical signs of neuromuscular blockade to determine adequacy of neuromuscular blockage and the need to adjust the NIMBEX dosage. Shorter durations of neuromuscular block may occur and NIMBEX infusion rate requirements may be higher in patients chronically administered phenytoin or carbamazepine. Acid-base and/or serum electrolyte abnormalities may potentiate the action of neuromuscular blocking agents. Certain drugs may enhance the neuromuscular blocking action of NIMBEX, including inhalational anesthetics, antibiotics, magnesium salts, lithium, local anesthetics, procainamide, and quinidine.It should not be used multiple times because it does not contain a preservative, and there is a higher risk of infection. The 20-mL vial of NIMBEX is intended only for administration as an infusion for use in a single patient in the ICU.Monitor patients to ensure that the level of anesthesia is adequate. Use NIMBEX in the presence of appropriate sedation or general anesthesia. Neuromuscular blockade in the conscious patient can lead to distress.Administration of NIMBEX results in paralysis, which may lead to respiratory arrest and death, a progression that may be more likely to occur in a patient for whom it is not intended. Confirm proper selection of intended product, avoid confusion with other injectable solutions, and ensure that the intended dose is clearly labelled and communicated.Precaution should be taken in those individuals who have had previous anaphylactic reactions to other neuromuscular blocking agents. There have been reports of wheezing, laryngospasm, bronchospasm, rash, and itching following NIMBEX administration in pediatric patients. Severe hypersensitivity reactions to NIMBEX have been reported, including life-threatening and fatal anaphylactic reactions.The level of neuromuscular blockade during long-term NIMBEX administration should be monitored with a nerve stimulator to titrate NIMBEX administration to the patient’s needs and limit exposure to toxic metabolites. Patients with renal or hepatic impairment receiving extended administration of NIMBEX may be at higher risk of seizures. NIMBEX-treated patients with renal or hepatic impairment may have higher metabolite concentrations (including laudanosine) than patients with normal renal and hepatic function. Laudanosine, an active metabolite of NIMBEX, has been shown to cause seizures in animals.Single-use vials (5-mL and 20-mL) of NIMBEX do not contain benzyl alcohol. Serious and fatal adverse reactions including “gasping syndrome,” which is characterized by central nervous system depression, metabolic acidosis, and gasping respirations, can occur in neonates and infants treated with benzyl alcohol–preserved drugs, including NIMBEX 10-mL multiple-dose vials.A lower maximum initial bolus is recommended in these patients to prevent complications. NIMBEX has been associated with residual paralysis patients with neuromuscular disease and carcinomatosis may be at higher risk.The use of 10-mL NIMBEX multiple-dose vials is contraindicated in pediatric patients less than 1 month of age and low birth-weight infants because the formulation contains benzyl alcohol. NIMBEX is contraindicated in patients with known hypersensitivity to cisatracurium severe anaphylactic reactions have been reported.NIMBEX is not recommended for rapid sequence endotracheal intubation. NIMBEX ® (cisatracurium besylate) is indicated as an adjunct to general anesthesia to facilitate tracheal intubation in adults and in pediatric patients 1 month to 12 years of age to provide skeletal muscle relaxation in adults during surgical procedures or mechanical ventilation in the ICU and to provide skeletal muscle relaxation during surgical procedures via infusion in pediatric patients 2 years and older. INDICATION AND IMPORTANT SAFETY INFORMATION FOR NIMBEX ® (cisatracurium besylate) INDICATION 2
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