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CISATRACURIO HIKMA 2 mg/ml INJECTABLE SOLUTION AND PERFUSION SOLUTION

CISATRACURIO HIKMA 2 mg/ml INJECTABLE SOLUTION AND PERFUSION SOLUTION

Ask a doctor about a prescription for CISATRACURIO HIKMA 2 mg/ml INJECTABLE SOLUTION AND PERFUSION SOLUTION

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Doctor

Tarek Agami

General medicine10 years of experience

Dr. Tarek Agami is a general practitioner registered in both Portugal and Israel, with broad experience in family and preventive medicine. He offers online consultations for adults and children, providing personalised support for primary care needs, chronic disease management, and everyday health concerns.

Dr. Agami received clinical training and worked in leading medical institutions in Israel (Kaplan Medical Center, Barzilai Medical Center, Wolfson Medical Center) and Portugal (European Healthcare City, Viscura Internacional, Hospital Dr. José Maria Grande, Hospital Vila Franca de Xira). His approach combines international medical standards with individualised attention to each patient.

Main areas of consultation:

  • Diagnosis and treatment of acute and chronic conditions (high blood pressure, diabetes, respiratory infections, cardiovascular symptoms)
  • Evaluation of symptoms and guidance on further diagnostic testing
  • Preventive check-ups and regular health monitoring
  • Medical support during travel or after relocation
  • Treatment adjustments and lifestyle recommendations based on your personal history
Dr. Agami provides medical support for patients using GLP-1 medications (such as Ozempic or Mounjaro) as part of a weight loss strategy. He offers individualised treatment planning, regular follow-up, dose adjustment, and advice on combining medication with sustainable lifestyle changes. Consultations follow the medical standards accepted in Portugal and Israel.

Dr. Agami is committed to evidence-based, patient-centred care, ensuring that each person receives trusted medical support tailored to their health goals.

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This page is for general information. Consult a doctor for personal advice. Call emergency services if symptoms are severe.
About the medicine

How to use CISATRACURIO HIKMA 2 mg/ml INJECTABLE SOLUTION AND PERFUSION SOLUTION

Introduction

Package Leaflet: Information for the User

Cisatracurium Hikma 2 mg/ml Solution for Injection and Infusion EFG

Read all of this leaflet carefully before you start using this medicine because it contains important information for you.

  • Keep this leaflet, you may need to read it again.
  • If you have any further questions, ask your doctor or pharmacist.
  • This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours.
  • If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. See section 4.

Contents of the Package Leaflet

  1. What is Cisatracurium Hikma and what is it used for
  2. What you need to know before you use Cisatracurium Hikma
  3. How to use Cisatracurium Hikma
  4. Possible side effects
  5. Storage of Cisatracurium Hikma
  6. Contents of the pack and further information

1. What is Cisatracurium Hikma and what is it used for

Cisatracurium Hikma contains a medicine called cisatracurium. This belongs to a group of medicines called muscle relaxants.

Cisatracurium is used to:

  • relax muscles during surgical operations, including heart surgery, in adults and children over 1 month old;
  • help insert a tube into the windpipe (tracheal intubation), if a person needs help with breathing;
  • relax muscles in adults in intensive care.

Ask your doctor if you need more information about this medicine.

2. What you need to know before you use Cisatracurium Hikma

Do not use Cisatracurium Hikma

  • if you are allergic to cisatracurium or other muscle relaxants or any of the other ingredients of this medicine (listed in section 6).
  • if you have had a bad reaction to an anaesthetic in the past.

Cisatracurium should not be given to you if you have any of the above conditions. If you are not sure, talk to your doctor, nurse or pharmacist before you are given this medicine.

Warnings and precautions

Tell your doctor, pharmacist or nurse before you start using this medicine if:

  • you have muscle weakness, tiredness or difficulty coordinating your movements (myasthenia gravis);
  • you have a nerve disease that causes muscle wasting, paralysis, motor neurone disease or cerebral palsy;
  • you have burns that need medical treatment;
  • you have ever had an allergic reaction to any muscle relaxant that you have been given during an operation.

If you are not sure if any of the above applies to you, talk to your doctor, nurse or pharmacist before you are given this medicine.

Other medicines and Cisatracurium Hikma

Tell your doctor if you are taking or have recently taken any other medicines, including medicines obtained without a prescription. In particular, tell your doctor if you are taking any of the following medicines:

  • anaesthetics (used to reduce feeling and pain during surgery);
  • antibiotics (used to treat infections);
  • medicines used to treat irregular heartbeats (anti-arrhythmics);
  • medicines used to treat high blood pressure;
  • medicines that help get rid of fluids (diuretics), such as furosemide;
  • medicines for joint inflammation, such as chloroquine or D-penicillamine;
  • corticosteroids;
  • medicines for epilepsy (seizures), such as phenytoin or carbamazepine;
  • medicines for mental illness, such as lithium, monoamine oxidase inhibitors (MAOIs) or chlorpromazine (which can also be used for nausea);
  • medicines that contain magnesium;
  • medicines for Alzheimer's disease (anticholinesterases, such as donepezil).

Pregnancy and breast-feeding

If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor for advice before you are given this medicine.

A harmful effect of cisatracurium on the baby cannot be excluded; however, it is unlikely to occur if breast-feeding is restarted after the effects of the substance have disappeared. Cisatracurium is rapidly eliminated from the body. Women should not breast-feed for 3 hours after the end of treatment.

Driving and using machines

If you are going to be in hospital for just one day, your doctor will tell you how long to wait before you can leave hospital or drive. It may be dangerous to drive soon after you have had an operation.

3. How to use Cisatracurium Hikma

Never try to give yourself this medicine. It should always be given by a person who is qualified to do so. Cisatracurium can be given:

  • as a single injection into a vein (intravenous bolus injection);
  • as a continuous infusion into a vein. This is when the medicine is given slowly over a long period of time.

Your doctor will decide how and how much of the medicine you will be given. This will depend on:

  • your body weight;
  • how much and how long you need muscle relaxation;
  • how you are expected to respond to the medicine.

This medicine should not be given to children under 1 month old.

If you have been given too much Cisatracurium Hikma

This medicine will always be given in carefully controlled conditions. However, if you think you have been given too much, tell your doctor or nurse immediately.

4. Possible side effects

Like all medicines, this medicine can cause side effects, although not everybody gets them.

If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet.

Allergic reactions (may affect up to 1 in 10,000 people)

If you get an allergic reaction, tell your doctor or nurse immediately. The signs may include:

  • sudden wheezing, chest pain or tightness;
  • swelling of the eyelids, face, lips, mouth or tongue;
  • skin rash or hives anywhere on the body;
  • collapse and anaphylactic shock.

Tell your doctor, nurse or pharmacist if you notice any of the following:

Common (may affect up to 1 in 10 people)

  • decrease in heart rate;
  • decrease in blood pressure.

Uncommon (may affect up to 1 in 100 people)

  • skin rash or redness;
  • wheezing or coughing.

Rare (may affect up to 1 in 10,000 people)

  • muscle weakness or pain.

Reporting of side effects

If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the Spanish Medicines and Healthcare Products Agency (AEMPS) website (http://www.aemps.gob.es/). By reporting side effects, you can help provide more information on the safety of this medicine.

5. Storage of Cisatracurium Hikma

  • Keep this medicine out of the sight and reach of children.
  • Do not use this medicine after the expiry date which is stated on the carton after “EXP”. The expiry date refers to the last day of that month.
  • Store in a refrigerator (2°C - 8°C). Do not freeze.
  • Store in the original package to protect from light.
  • If diluted, store the infusion solution at 25°C or 2-8°C and use within 24 hours. Any unused infusion solution should be discarded 24 hours after preparation.
  • Medicines should not be disposed of via wastewater or household waste. Your doctor or nurse will dispose of any unused medicine. This will help protect the environment.

6. Contents of the pack and further information

What Cisatracurium Hikma contains

  • The active substance is 2 mg/ml cisatracurium (as besilate).
  • The other ingredients are benzenesulfonic acid (for pH adjustment) and water for injections.

Appearance and packaging

Cisatracurium Hikma 2 mg/ml Solution for Injection and Infusion is a colourless to pale yellow or yellowish-green solution, practically free from visible particles, and is available in:

  • Boxes of 5 and 10 glass ampoules of 2.5 ml (each 2.5 ml ampoule contains 5 mg of cisatracurium).
  • Boxes of 5 and 10 glass ampoules of 5 ml (each 5 ml ampoule contains 10 mg of cisatracurium).
  • Boxes of 5 and 10 glass ampoules of 10 ml (each 10 ml ampoule contains 20 mg of cisatracurium).

Not all pack sizes may be marketed.

Marketing authorisation holder and manufacturer

Marketing authorisation holder

Hikma Farmacêutica (Portugal), S.A.

Estrada do Rio da Mó, 8, 8A e 8B - Fervença

2705-906 Terrugem SNT

Portugal

Manufacturer

Hikma Italia S.P.A.

Viale Certosa 10

27100 Pavia

Italy

You can obtain further information on this medicine from the representative of the marketing authorisation holder:

Hikma España, S.L.U.

Calle Anabel Segura nº11, Edificio A, planta 1ª, oficina 2

28108 - Alcobendas, Madrid

Spain

This medicine is authorised in the Member States of the European Economic Area under the following names:

Austria: Cisatracurium Hikma 2 mg/ml Injektionslösung oder Infusionslösung

Germany: Cisatracurium Hikma 2 mg/ml Injektionslösung /Infusionslösung

Belgium: Cisatracurium Hikma 2 mg/ml Injektions/Infusionslösung/Solution injectable/pour perfusion/ Oplossing voor injectie / infusie

Spain: Cisatracurio Hikma 2 mg/ml solución inyectable y para perfusión EFG

France: Cisatracurium Hikma 2 mg/ml Solution injectable/pour perfusion

Italy: Cisatracurio Hikma 2 mg/ml Soluzione iniettabile infusione

Netherlands: Cisatracurium Hikma 2 mg/ml Oplossing voor injectie/ infusie

Portugal: Cisatracúrio Hikma

United Kingdom: Cisatracurium 2 mg/ml Solution for injection/infusion

Date of last revision of this leaflet: July 2024

Detailed information on this medicine is available on the website of the Spanish Agency for Medicines and Healthcare Products (AEMPS) (http://www.aemps.gob.es/).

--------------------------------------------------------------------------------------------------------------------

This information is intended only for healthcare professionals:

This product is for single use only. Use only clear and almost colourless or slightly yellowish/greenish solutions. The product should be inspected visually before use, and if the appearance has changed or the container is damaged, the product should be discarded.

Diluted Cisatracurium Hikma remains physically and chemically stable for at least 24 hours at 2-8°C and 25°C at concentrations between 0.1 and 2 mg/ml in the following infusion fluids, either in polyvinyl chloride or polypropylene containers.

Intravenous infusion of sodium chloride (0.9% w/v).

Intravenous infusion of glucose (5% w/v).

Intravenous infusion of sodium chloride (0.18% w/v) and glucose (4.5% w/v) (one-fifth of the usual concentration of glucose).

Intravenous infusion of sodium chloride (0.45% w/v) and glucose (5% w/v).

In any case, since the product does not contain antimicrobial preservatives, dilution should be made immediately before use or, if this is not possible, it can be stored according to section 5 of the leaflet.

Cisatracurium Hikma has been shown to be compatible with the following drugs commonly used in surgical procedures, when mixed under conditions simulating intravenous infusion through a "Y" device: alfentanil hydrochloride, droperidol, fentanyl citrate, midazolam hydrochloride and sufentanil citrate. When other drugs are administered through the same needle or cannula as cisatracurium, it is recommended that each drug be flushed through with a suitable volume of an intravenous fluid, such as sodium chloride 0.9% w/v infusion.

As with other drugs administered intravenously, when a small vein is selected as the injection site, this medicine should be flushed through the vein with a suitable intravenous fluid, for example, sodium chloride 0.9% w/v infusion.

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Online doctors for CISATRACURIO HIKMA 2 mg/ml INJECTABLE SOLUTION AND PERFUSION SOLUTION

Discuss dosage, side effects, interactions, contraindications, and prescription renewal for CISATRACURIO HIKMA 2 mg/ml INJECTABLE SOLUTION AND PERFUSION SOLUTION – subject to medical assessment and local rules.

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Doctor

Tarek Agami

General medicine10 years of experience

Dr. Tarek Agami is a general practitioner registered in both Portugal and Israel, with broad experience in family and preventive medicine. He offers online consultations for adults and children, providing personalised support for primary care needs, chronic disease management, and everyday health concerns.

Dr. Agami received clinical training and worked in leading medical institutions in Israel (Kaplan Medical Center, Barzilai Medical Center, Wolfson Medical Center) and Portugal (European Healthcare City, Viscura Internacional, Hospital Dr. José Maria Grande, Hospital Vila Franca de Xira). His approach combines international medical standards with individualised attention to each patient.

Main areas of consultation:

  • Diagnosis and treatment of acute and chronic conditions (high blood pressure, diabetes, respiratory infections, cardiovascular symptoms)
  • Evaluation of symptoms and guidance on further diagnostic testing
  • Preventive check-ups and regular health monitoring
  • Medical support during travel or after relocation
  • Treatment adjustments and lifestyle recommendations based on your personal history
Dr. Agami provides medical support for patients using GLP-1 medications (such as Ozempic or Mounjaro) as part of a weight loss strategy. He offers individualised treatment planning, regular follow-up, dose adjustment, and advice on combining medication with sustainable lifestyle changes. Consultations follow the medical standards accepted in Portugal and Israel.

Dr. Agami is committed to evidence-based, patient-centred care, ensuring that each person receives trusted medical support tailored to their health goals.

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  • Chest pain, shortness of breath, heart palpitations, high blood pressure
  • Hypertension control and cardiovascular disease prevention
  • Interpretation of ECG, blood tests, and Holter monitor results
  • Management of heart failure and coronary artery disease
  • General medical issues: infections, fever, fatigue, gastrointestinal symptoms
  • Guidance on diagnostics, treatment plans, and medication adjustments
Dr. Alhasan’s approach is based on thorough assessment, clear communication, and personalised care – helping patients understand their health and make informed decisions about their treatment.
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  • Emergency care: infections, fever, chest/abdominal pain, minor injuries, paediatric emergencies
  • Family medicine: hypertension, diabetes, cholesterol, chronic disease management
  • Travel medicine: pre-travel advice, vaccinations, fit-to-fly certificates, travel-related illnesses
  • Sexual and reproductive health: PrEP, STD prevention, counselling, treatment
  • Weight management and wellness: personalised weight loss programmes, lifestyle guidance
  • Skin and ENT issues: acne, eczema, allergies, rashes, sore throat, sinusitis
  • Pain management: acute and chronic pain, post-surgical care
  • Public health: prevention, health screenings, long-term monitoring
  • Sick leave (Baixa médica) connected to Segurança Social in Portugal
  • IMT medical certificates for driving licence exchange
Dr. Lopes also provides interpretation of medical tests, follow-up care for complex patients, and multilingual support. Whether for urgent concerns or long-term care, he helps patients act with clarity and confidence.
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  • Common symptoms such as fever, sore throat, cough, fatigue, or digestive issues
  • Chronic conditions including hypertension, diabetes, high cholesterol, and thyroid problems
  • Mental health concerns such as stress, sleep issues, anxiety, and burnout
  • Preventive care: health check-ups, lifestyle advice, and follow-up for existing conditions
  • Work-related health questions, sick leave documentation, and medical guidance for returning to work
Dr. Meneses graduated from the University of Beira Interior and has years of experience working with diverse patient populations. He is fluent in Portuguese, English, Spanish, and French.

His approach is friendly, clear, and focused on delivering practical medical advice tailored to each patient’s needs.

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Key areas of consultation:

  • Preventive and family medicine
  • Women’s health, including gynaecology and obstetrics
  • Chronic disease management: hypertension, diabetes, and more
  • Mental health support, anxiety, and counselling
  • Postoperative care and lab test interpretation
She has conducted research on the genetic background of stroke and is skilled in communicating with patients from diverse cultural backgrounds. Her approach combines clinical expertise with empathy and clear communication.
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Dr. Muhammad Tayyab Altaf is a primary care physician with extensive international experience, offering online consultations for adults and children. His background includes clinical practice in Italy, the United States and other healthcare settings, allowing him to manage a wide range of acute and chronic medical conditions with confidence and clarity. He trained at leading institutions such as IRCCS Policlinico San Matteo in Pavia, Mount Sinai Hospital in New York, Baptist Hospital in Texas and a private practice in Dallas, working across outpatient care, inpatient medicine, intensive care, hospice and nursing home management.

His clinical expertise spans multi-system conditions, preventive care and long-term management of chronic diseases. Dr. Altaf combines hands-on experience with a strong research background in both medical and surgical fields, enabling him to provide accurate assessments and structured, evidence-based treatment plans. Patients value his ability to explain diagnoses clearly, outline next steps and support them in making informed healthcare decisions.

Online consultations with Dr. Altaf are suitable for many everyday and acute situations where a timely medical opinion can help determine the safest next steps. He evaluates and treats conditions affecting the cardiovascular, respiratory, gastrointestinal, neurological, haematological and endocrine systems. Common examples include:

  • hypertension and other blood pressure issues
  • ischaemic heart disease and angina
  • asthma, COPD and emphysema
  • pneumonia and lung fibrosis
  • gastroenteritis and digestive infections
  • liver conditions, including alcohol-related disease
  • epilepsy, seizures and post-stroke symptoms
  • dementia and cognitive decline
  • anaemia and other haematological changes
  • diabetes, thyroid disorders and pituitary disease
Many patients reach out when they experience new or worsening symptoms, fluctuations in blood pressure, non-severe chest discomfort, breathing symptoms, digestive issues, suspected infections, chronic fatigue or concerns that affect daily life. He also helps patients understand test results, adjust existing treatment plans and navigate long-term health strategies safely and effectively.

When clinically appropriate, Dr. Altaf can also provide health and fitness certificates, including documentation required for physical activity, sports participation or gym use, based on the patient’s health status and medical indications.

Some conditions are not suitable for online care. Severe chest pain, loss of consciousness, uncontrolled bleeding, seizures, major trauma or symptoms suggesting a stroke or heart attack require immediate attention from local emergency services. Dr. Altaf prioritises patient safety and will guide you accordingly if your situation needs urgent in-person care.

In all consultations, Dr. Muhammad Tayyab Altaf focuses on clear communication, accurate diagnosis and patient-centred decision-making. His approach ensures that individuals and families feel informed, supported and confident in their next steps, no matter where they are.

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His areas of focus include:

  • General and urgent care: fever, fatigue, infections, digestive issues, respiratory symptoms, and other common concerns
  • Chronic condition support: hypertension, high cholesterol, diabetes, thyroid issues
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  • Trichology: hair loss, scalp conditions, treatment strategies for men and women
  • Preventive care: health check-ups, lifestyle advice, second opinions

Dr. Correa combines medical knowledge with an aesthetic and holistic approach to help patients improve both health and quality of life.

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Hocine Lokchiri

General medicine20 years of experience

Dr. Hocine Lokchiri is a French consultant with over 20 years of experience in General and Emergency Medicine. He works with adults and children, helping patients with urgent symptoms, infections, sudden health changes and everyday medical concerns that require timely evaluation. His background includes clinical practice in France, Switzerland and the United Arab Emirates, which allows him to navigate different healthcare systems and manage a wide range of conditions with confidence. Patients value his calm, structured approach, clear explanations and evidence-based decision-making.

Online consultations with Dr. Lokchiri are suitable for many situations when someone needs quick medical guidance, reassurance or a clear next step. Common reasons for booking include:

  • fever, chills, fatigue and viral symptoms
  • cough, sore throat, nasal congestion, breathing discomfort
  • bronchitis and mild asthma flare-ups
  • nausea, diarrhoea, abdominal pain, digestive infections
  • rashes, allergic reactions, redness, insect bites
  • muscle or joint pain, mild injuries, sprains
  • headache, dizziness, migraine symptoms
  • stress-related symptoms, sleep disturbances
  • questions about test results and treatment plans
  • management of chronic conditions in stable phases
Many patients reach out when symptoms appear suddenly and cause concern, when a child becomes unwell unexpectedly, when a rash changes or spreads, or when it’s unclear whether an in-person examination is necessary. His emergency medicine background is particularly valuable online, helping patients understand risk levels, identify warning signs and choose safe next steps.

Some situations are not suitable for online care. If a patient has loss of consciousness, severe chest pain, uncontrolled bleeding, seizures, major trauma or symptoms suggesting a stroke or heart attack, he will advise seeking immediate local emergency services. This improves safety and ensures patients receive the right level of care.

Dr. Lokchiri’s professional training includes:

  • Advanced Trauma Life Support (ATLS)
  • Basic and Advanced Cardiac Life Support (BLS/ACLS)
  • Pediatric Advanced Life Support (PALS)
  • Prehospital Trauma Life Support (PHTLS)
  • eFAST and critical care transthoracic echocardiography
  • aviation medicine
He is an active member of several professional organisations, including the French Society of Emergency Medicine (SFMU), the French Association for Emergency Physicians (AMUF) and the Swiss Society of Emergency and Rescue Medicine (SGNOR). In consultations, he works with clarity and precision, helping patients understand their symptoms, possible risks and the safest treatment options.
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Andrei Popov

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Dr. Andrei Popov is a licensed pain management specialist and general practitioner based in Spain. He provides expert online care for adults dealing with both chronic and acute pain, as well as a wide range of everyday health concerns.

He specialises in diagnosing and treating pain conditions that affect quality of life, including:

  • Chronic pain lasting more than 3 months.
  • Migraines and recurring headaches.
  • Neck, back, lower back, and joint pain.
  • Post-traumatic pain following injury or surgery.
  • Nerve-related pain, fibromyalgia, and neuralgia.
In addition to pain management, Dr. Popov helps patients with:
  • Respiratory infections (colds, bronchitis, pneumonia).
  • High blood pressure and metabolic conditions such as diabetes.
  • Preventive care and routine health check-ups.

Online consultations last up to 30 minutes and include a detailed symptom review, personalised treatment planning, and medical follow-up when needed.

Dr. Popov’s approach is rooted in evidence-based medicine, combined with individualised care tailored to each patient’s history, lifestyle, and clinical needs.

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Yevgen Yakovenko

General surgery11 years of experience

Dr. Yevgen Yakovenko is a licensed surgeon and general practitioner in Spain and Germany. He specialises in general, paediatric, and oncological surgery, internal medicine, and pain management. He offers online consultations for adults and children, combining surgical precision with therapeutic support. Dr Yakovenko works with patients across different countries and provides care in Ukrainian, Russian, English, and Spanish.

Areas of medical expertise:

  • Acute and chronic pain: headaches, muscle and joint pain, back pain, abdominal pain, postoperative pain. Identifying the cause, selecting treatment, and creating a care plan.
  • Internal medicine: heart, lungs, gastrointestinal tract, urinary system. Management of chronic conditions, symptom control, second opinions.
  • Pre- and postoperative care: risk assessment, decision-making support, follow-up after surgery, rehabilitation strategies.
  • General and paediatric surgery: hernias, appendicitis, congenital conditions, both planned and urgent surgeries.
  • Injuries and trauma: bruises, fractures, sprains, soft tissue damage, wound care, dressing, referral when in-person care is required.
  • Oncological surgery: diagnosis review, treatment planning, and long-term follow-up.
  • Obesity treatment and weight management: a medical approach to weight loss, including assessment of underlying causes, evaluation of comorbidities, development of a personalised plan (nutrition, physical activity, pharmacotherapy if needed), and ongoing progress monitoring.
  • Imaging interpretation: analysis of ultrasound, CT, MRI, and X-ray results, surgical planning based on imaging data.
  • Second opinions and medical navigation: clarifying diagnoses, reviewing current treatment plans, helping patients choose the best course of action.

Experience and qualifications:

  • 12+ years of clinical experience in university hospitals in Germany and Spain.
  • International education: Ukraine – Germany – Spain.
  • Member of the German Society of Surgeons (BDC).
  • Certified in radiological diagnostics and robotic surgery.
  • Active participant in international medical conferences and research.

Dr Yakovenko explains complex topics in a clear, accessible way. He works collaboratively with patients to analyse health issues and make evidence-based decisions. His approach is grounded in clinical excellence, scientific accuracy, and respect for each individual.

If you are unsure about a diagnosis, preparing for surgery, or want to discuss your test results – Dr Yakovenko will help you evaluate your options and move forward with confidence.

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