Atracurium

Pharmacologic Category

Neuromuscular Blocker Agent, Nondepolarizing

Dosing: Adult

Note: Dose to effect; doses must be individualized due to interpatient variability. Ensure adequate pain control and sedation prior to and during administration of neuromuscular blockade to achieve deep sedation (SCCM [Murray 2016]).

Intensive care unit paralysis (eg, use for up to 48 hours in patients with early ARDS with PaO2/FiO2 <150, to facilitate mechanical ventilation, or for shivering from therapeutic hypothermia) (off-label dosing): IV: Initial bolus of 0.4 to 0.5 mg/kg, followed by 4 to 20 mcg/kg/minute (0.24 to 1.2 mg/kg/hour) (ACCM/SCCM/ASHP [Murray 2002]; Greenberg 2013; SCCM [Murray 2016])

Neuromuscular blockade for endotracheal intubation, surgery, or mechanical ventilation (as adjunct to general anesthesia):

IV (bolus): 0.4 to 0.5 mg/kg, then 0.08 to 0.1 mg/kg administered 20 to 45 minutes after initial dose to maintain neuromuscular block; repeat dose at 15- to 25-minute intervals as needed. Note: Initial dose may be reduced to 0.3 to 0.4 mg/kg in patients with significant cardiovascular disease (increased incidence of hypotension) or history of elevated risk of histamine release (eg, severe anaphylactoid reactions or asthma).

Initial dose after succinylcholine for intubation (balanced anesthesia): 0.3 to 0.4 mg/kg

Pretreatment/priming: 10% of intubating dose (eg, 0.04 to 0.05 mg/kg) given 2 to 4 minutes before the larger second dose (Mehta 1985; Miller 2010). Note: Although priming has been advocated by some, priming may either be uncomfortable for the patient, increase the risk of aspiration and difficulty swallowing, or intubating conditions after priming may not be as good as that seen with succinylcholine (Miller 2010).

Maintenance infusion for continued surgical relaxation during extended surgical procedures: At initial signs of recovery from bolus dose, a continuous infusion may be initiated at a rate of 9 to 10 mcg/kg/minute (0.54 to 0.6 mg/kg/hour); block usually maintained by a rate of 5 to 9 mcg/kg/minute (0.3 to 0.54 mg/kg/hour) under balanced anesthesia; range: 2 to 15 mcg/kg/minute (0.12 to 0.9 mg/kg/hour)

* See Dosage and Administration in AHFS Essentials for additional information.

Dosing: Geriatric

Refer to adult dosing.

Dosing: Renal Impairment: Adult

No dosage adjustment necessary.

Dosing: Hepatic Impairment: Adult

No dosage adjustment necessary.

Dosing: Obesity: Adult

Obese and morbidly obese patients should be dosed using ideal body weight or an adjusted body weight (ie, between IBW and total body weight [TBW]) (Erstad 2004; SCCM [Murray 2016]). In a bariatric surgical population of morbidly obese patients who were administered an induction dose of atracurium based on TBW as compared to IBW, time to recovery of twitch response was prolonged (Kralingen 2011).

Dosing: Pediatric

Note: Dose to effect; doses must be individualized due to interpatient variability. Dosing in obese patients should be calculated using ideal body weight (Playfor 2007):

Adjunct to surgical anesthesia (neuromuscular blockade): Note: Maintenance doses in infants and children may need to be administered with slightly greater frequency compared to adults.

Initial:

Infants and Children <2 years: IV: 0.3 to 0.4 mg/kg, additional doses of 0.3 to 0.4 mg/kg may be repeated as needed to maintain neuromuscular blockade

Children ≥2 years and Adolescents: IV: 0.4 to 0.5 mg/kg once followed by 0.08 to 0.1 mg/kg 20 to 45 minutes after initial dose to maintain neuromuscular block; repeat dose at 15- to 25-minute intervals as needed

Maintenance infusion for continued surgical relaxation during extended surgical procedures:

Infants and Children <2 years: Continuous IV infusion: 6 to 14 mcg/kg/minute (0.4 to 0.8 mg/kg/hour) (Goudsouzian 1986; Goudsouzian 1988)

Children ≥2 years and Adolescents: Continuous IV infusion: Initial: 9 to 10 mcg/kg/minute (0.54 to 0.6 mg/kg/hour) at initial signs of recovery from bolus dose; block is usually maintained by a rate of 5 to 9 mcg/kg/minute (0.3 to 0.54 mg/kg/hour); range: 2 to 15 mcg/kg/minute (0.1 to 0.9 mg/kg/hour)

ICU paralysis (eg, facilitate mechanical ventilation) in selected adequately sedated patients: Infants, Children, and Adolescents: IV: Initial bolus: 0.3 to 0.6 mg/kg, followed by continuous IV infusion of 5 to 28 mcg/kg/minute (0.3 to 1.7 mg/kg/hour) (Martin 1999; Playfor 2007)

Dosing: Renal Impairment: Pediatric

Infants, Children, and Adolescents: No dosage adjustment necessary.

Dosing: Hepatic Impairment: Pediatric

Infants, Children, and Adolescents: No dosage adjustment necessary.

Calculations

• Atracurium

Use: Labeled Indications

Neuromuscular blockade for endotracheal intubation, surgery, or mechanical ventilation: As an adjunct to general anesthesia, to facilitate endotracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation in adequately sedated ICU patients

Note: Neuromuscular blockade does not provide pain control, sedation, or amnestic effects. Appropriate analgesic and sedative mediations should be used before and during administration of neuromuscular blockade to achieve deep sedation.

* See Uses in AHFS Essentials for additional information.

Use: Off-Label: Adult

Acute respiratory distress syndromeLevel of Evidence [G]

Based on the Society for Critical Care Medicine Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient, a neuromuscular blocker may be considered for short-term use (up to 48 hours) during the early course of acute respiratory distress syndrome (ARDS) in adults with PaO2/FiO2 <150 mmHg Ref. Some experts recommend that neuromuscular blockers be considered for short-term use (up to 48 hours) only in patients with ARDS and severe gas exchange abnormalities (PaO2/FiO2 ≤120 mmHg) Ref. Note: Only cisatracurium has been studied in patients with ARDS. Whether or not other neuromuscular blockers will yield similar results is unknown.

Shivering due to therapeutic hypothermia following cardiac arrestLevel of Evidence [G]

Based on the Society for Critical Care Medicine Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient, a neuromuscular blocker may be used to manage overt shivering in therapeutic hypothermia following cardiac arrest.

Level of Evidence Definitions

Level of Evidence Scale

Clinical Practice Guidelines

Coronavirus Disease 2019 (COVID-19):

“Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19),” March 2020

Critical Care:

ACCM/SCCM/ASHP, “Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient,” January 2002

SCCM, “Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient,” 2016

“Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016,” March 2017

Usual Infusion Concentrations: Adult

IV infusion: 20 mg in 100 mL (concentration: 0.2 mg/mL) or 50 mg in 100 mL (concentration: 0.5 mg/mL) of D5W, D5NS, or NS.

Administration: IV

May be given undiluted as a bolus injection; do not administer IM (excessive tissue irritation). May also administer via continuous infusion; requires the use of an infusion pump. Use infusion solutions within 24 hours of preparation.

Administration: Injectable Detail

pH: 3.25 to 3.65 (undiluted vial)

Administration: Pediatric

Parenteral: May be administered undiluted as a bolus IV injection; do not administer IM due to tissue irritation. For continuous IV infusions, further dilute and administer via an infusion pump; use infusion solutions within 24 hours of preparation.

Storage/Stability

Store intact vials at 2°C to 8°C (36°F to 46°F). Do not freeze. Upon removal from refrigeration to room temperature storage conditions (25°C/77°F), use within 14 days even if re-refrigerated. Dilutions of 0.2 mg/mL or 0.5 mg/mL in 0.9% sodium chloride, dextrose 5% in water, or 5% dextrose in sodium chloride 0.9% are stable for up to 24 hours at room temperature or under refrigeration.

Preparation for Administration: Adult

May prepare an infusion solution (final concentrations: 0.2 mg/mL or 0.5 mg/mL) by admixing with an appropriate diluent (eg, NS, D5W, D5NS). Do not mix with alkaline solutions.

Preparation for Administration: Pediatric

Parenteral: For continuous IV infusion, dilute in D5W, NS or D5NS to a maximum concentration of 0.5 mg/mL. Atracurium should not be mixed with alkaline solutions.

Compatibility

See Trissel’s IV Compatibility Database

Open Trissel's IV Compatibility

Medication Patient Education with HCAHPS Considerations

What is this drug used for?

• It is used to calm muscles during surgery.

• It is used to calm muscles while on a breathing machine.

Frequently reported side effects of this drug

• Flushing

Other side effects of this drug: Talk with your doctor right away if you have any of these signs of:

• Severe dizziness

• Passing out

• Fast heartbeat

• Slow heartbeat

• Signs of a significant reaction like wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat.

Note: This is not a comprehensive list of all side effects. Talk to your doctor if you have questions.

Consumer Information Use and Disclaimer: This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.

Medication Safety Issues

High alert medication:

Other safety concerns:

Contraindications

Hypersensitivity to atracurium or any component of the formulation; known hypersensitivity to benzyl alcohol (multiple dose vials)

Documentation of allergenic cross-reactivity for neuromuscular blockers is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.

Warnings/Precautions

Concerns related to adverse effects:

• Anaphylaxis: Severe anaphylactic reactions have been reported with atracurium use; some life-threatening and fatal. Appropriate emergency treatment (including epinephrine 1 mg/mL) should be immediately available during use. Use caution in patients with previous anaphylactic reactions to other neuromuscular blocking agents.

• Bradycardia: May be more common with atracurium than with other neuromuscular-blocking agents since it has no clinically-significant effects on heart rate to counteract the bradycardia produced by anesthetics.

Disease-related concerns:

• Burn injury: Resistance may occur in burn patients (≥20% of total body surface area), usually several days after the injury, and may persist for several months after wound healing (Han 2009).

• Conditions that may antagonize neuromuscular blockade (decreased paralysis): Respiratory alkalosis, hypercalcemia, demyelinating lesions, peripheral neuropathies, denervation, and muscle trauma may result in antagonism of neuromuscular blockade (ACCM/SCCM/ASHP [Murray 2002]; Greenberg 2013; Miller 2010; Naguib 2002).

• Conditions that may potentiate neuromuscular blockade (increased paralysis): Electrolyte abnormalities (eg, severe hypocalcemia, severe hypokalemia, hypermagnesemia), neuromuscular diseases, metabolic acidosis, respiratory acidosis, Eaton-Lambert syndrome and myasthenia gravis may result in potentiation of neuromuscular blockade (Greenberg 2013; Miller 2010; Naguib 2002).

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Elderly: Use with caution in the elderly, effects and duration are more variable.

• Immobilized patients: Resistance may occur in patients who are immobilized.

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer’s labeling.

Other warnings/precautions:

• Appropriate use: Maintenance of an adequate airway and respiratory support is critical. Resistance may develop with chronic treatment. All patients should receive eye care including liberal use of lubricating drops, gel, or ointment, and eyelids should remain closed during continuous neuromuscular blockade to protect against damage to the cornea (ulceration and drying).

• Experienced personnel: Should be administered by adequately trained individuals familiar with its use.

• Histamine release: Reduce initial dosage and inject slowly (over 1 to 2 minutes) in patients in whom substantial histamine release would be potentially hazardous (eg, patients with clinically-important cardiovascular disease).

• Risk of medication errors: Accidental administration may be fatal. Confirm proper selection of intended product, store vial so the cap and ferrule are intact and the possibility of selecting the wrong product is minimized, and ensure that the intended dose is clearly labeled and communicated, when applicable.

* See Cautions in AHFS Essentials for additional information.

Pregnancy Risk Factor

C

Pregnancy Considerations

Small amounts of atracurium have been shown to cross the placenta when given to women during cesarean section.

Breast-Feeding Considerations

It is not known if atracurium is present in breast milk. The manufacturer recommends that caution be exercised when administering atracurium to breastfeeding women.

Briggs' Drugs in Pregnancy & Lactation

• Atracurium

Adverse Reactions

Frequency not defined. Adverse reactions are mild, rare, and generally suggestive of histamine release.

1% to 10%: Cardiovascular: Flushing

<1%, postmarketing, and/or case reports: Bradycardia, bronchospasm, dyspnea, erythema, hypersensitivity reaction, hypotension, increased bronchial secretions, injection site reaction, laryngospasm, pruritus, seizure, tachycardia, urticaria, wheezing

* See Cautions in AHFS Essentials for additional information.

Allergy and Idiosyncratic Reactions

• Neuromuscular-Blocking Agent Allergy

Metabolism/Transport Effects

None known.

Drug Interactions Open Interactions

Acetylcholinesterase Inhibitors: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy

Aminoglycosides: May enhance the therapeutic effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Bacitracin (Systemic): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Botulinum Toxin-Containing Products: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Bromperidol: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Calcium Channel Blockers: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy

Capreomycin: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

CarBAMazepine: May decrease the serum concentration of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy

Cardiac Glycosides: Neuromuscular-Blocking Agents may enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy

Clindamycin (Topical): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Colistimethate: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Management: If possible, avoid concomitant use of these products. Monitor for deeper, prolonged neuromuscular-blocking effects (respiratory paralysis) in patients receiving concomitant neuromuscular-blocking agents and colistimethate. Risk D: Consider therapy modification

Corticosteroids (Systemic): Neuromuscular-Blocking Agents (Nondepolarizing) may enhance the adverse neuromuscular effect of Corticosteroids (Systemic). Increased muscle weakness, possibly progressing to polyneuropathies and myopathies, may occur. Management: If concomitant therapy is required, use the lowest dose for the shortest duration to limit the risk of myopathy or neuropathy. Monitor for new onset or worsening muscle weakness, reduction or loss of deep tendon reflexes, and peripheral sensory decriments Risk D: Consider therapy modification

CycloSPORINE (Systemic): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Fosphenytoin-Phenytoin: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Fosphenytoin-Phenytoin may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Fosphenytoin-Phenytoin may decrease the serum concentration of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy

Inhalational Anesthetics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Management: When initiating a non-depolarizing neuromuscular blocking agent (NMBA) in a patient receiving an inhalational anesthetic, initial NMBA doses should be reduced 15% to 25% and doses of continuous infusions should be reduced 30% to 60%. Risk D: Consider therapy modification

Ketorolac (Nasal): May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents (Nondepolarizing). Specifically, episodes of apnea have been reported in patients using this combination. Risk C: Monitor therapy

Ketorolac (Systemic): May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents (Nondepolarizing). Specifically, episodes of apnea have been reported in patients using this combination. Risk C: Monitor therapy

Lincosamide Antibiotics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Lithium: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Local Anesthetics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Exceptions: Benzocaine; Benzydamine; Cocaine (Topical); Dibucaine; Dyclonine; Ethyl Chloride; Hexylresorcinol; Lidocaine (Ophthalmic); Lidocaine (Topical); Pramoxine; Proparacaine; Tetracaine (Ophthalmic); Tetracaine (Topical). Risk C: Monitor therapy

Loop Diuretics: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Loop Diuretics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Magnesium Salts: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Minocycline (Systemic): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Pholcodine: May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents. Specifically, anaphylaxis has been reported. Risk C: Monitor therapy

Polymyxin B: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Management: If possible, avoid concomitant use of neuromuscular-blocking agents and polymyxin B. If concomitant use cannot be avoided, monitor for deeper, prolonged neuromuscular-blocking effects (eg, respiratory paralysis) in patients receiving this combination. Risk D: Consider therapy modification

Procainamide: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

QuiNIDine: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

QuiNINE: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk X: Avoid combination

Spironolactone: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy

Tetracyclines: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Thiazide and Thiazide-Like Diuretics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy

Trimebutine: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy

Vancomycin: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Monitoring Parameters

Vital signs (heart rate, blood pressure, respiratory rate); degree of muscle paralysis (eg, presence of spontaneous movement, ventilator asynchrony, shivering, and consider use of a peripheral nerve stimulator with train of four monitoring along with clinical assessments)

In the ICU setting, prolonged paralysis and generalized myopathy, following discontinuation of agent, may be minimized by appropriately monitoring degree of blockade.

Advanced Practitioners Physical Assessment/Monitoring

Obtain heart rate, blood pressure, respiratory rate, and degree of muscle relaxation continuously during therapy. Ventilatory support must be instituted and maintained until adequate respiratory muscle function and/or airway protection are assured. Monitor for prolonged paralysis and generalized myopathy in patients on long-term therapy.

Nursing Physical Assessment/Monitoring

Ventilatory support must be instituted and maintained until adequate respiratory muscle function and/or airway protection are assured. Monitor vital signs, cardiac status, respiratory status, and degree of neuromuscular block as ordered. In patients on long-term therapy, monitor for prolonged paralysis and generalized myopathy and reposition patient and provide appropriate skin care, mouth care, and care of patient's eyes every 2 to 3 hours while sedated.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous, as besylate:

Generic: 100 mg/10 mL (10 mL)

Solution, Intravenous, as besylate [preservative free]:

Generic: 50 mg/5 mL (5 mL)

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution, Intravenous:

Generic: 10 mg/mL ([DSC])

Anatomic Therapeutic Chemical (ATC) Classification

• M03AC04

Generic Available (US)

Yes

Pricing: US

Solution (Atracurium Besylate Intravenous)

50 mg/5 mL (per mL): $1.14 - $1.92

100 mg/10 mL (per mL): $1.13 - $1.92

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Mechanism of Action

Blocks neural transmission at the myoneural junction by binding with cholinergic receptor sites

Pharmacodynamics/Kinetics

Onset of action (dose dependent): 2 to 3 minutes; Peak effect: 3 to 5 minutes

Duration: Recovery begins in 20 to 35 minutes following initial dose of 0.4 to 0.5 mg/kg under balanced anesthesia; recovery to 95% of control takes 60 to 70 minutes; hypothermia may prolong the duration of action

Distribution: Vd:

Infants: 0.21 L/kg

Children: 0.13 L/kg

Adults: 0.1 L/kg

Metabolism: Undergoes ester hydrolysis and Hofmann elimination (nonbiologic process independent of renal, hepatic, or enzymatic function); metabolites have no neuromuscular blocking properties; laudanosine, a product of Hofmann elimination, is a CNS stimulant and can accumulate with prolonged use. Laudanosine is hepatically metabolized.

Half-life elimination:

Infants: 20 minutes

Children: 17 minutes

Adults: Biphasic: Initial (distribution): 2 minutes; Terminal: 20 minutes

Excretion: Urine (<5%)

Clearance:

Infants: 7.9 mL/kg/minute

Children: 6.8 mL/kg/minute

Adults: 5.3 mL/kg/minute

Local Anesthetic/Vasoconstrictor Precautions

No information available to require special precautions

Effects on Dental Treatment

No significant effects or complications reported

Effects on Bleeding

No information available to require special precautions

Related Information

• Dosing Considerations for the Critically Ill Patient With Morbid Obesity
• Neuromuscular-Blocking Agents

Pharmacotherapy Pearls

Atracurium is classified as an intermediate-duration neuromuscular-blocking agent. It does not appear to have a cumulative effect on the duration of blockade.

Index Terms

Atracurium Besylate

FDA Approval Date

November 23, 1983

References

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Meretoja OA, Taivainen T, Jalkanen L, et al, “Synergism Between Atracurium and Vecuronium in Infants and Children During Nitrous Oxide-Oxygen-Alfentanil Anaesthesia,” Br J Anaesth, 1994, 73(5):605-7.[PubMed 7826787]

Miller RD. Miller’s Anesthesia, 7th ed. Philadelphia PA: Churchill Livingstone, 2010.

Murray MJ, Cowen J, DeBlock H, et al, “Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient. Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists, American College of Chest Physicians,” Crit Care Med, 2002, 30(1):142-56.[PubMed 11902255]

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Yate PM, Flynn PJ, Arnold RW, et al, “Clinical Experience and Plasma Laudanosine Concentrations During the Infusion of Atracurium in the Intensive Therapy Unit,” Br J Anaesth, 1987, 59(2):211-7.[PubMed 3548792]

Brand Names: International

Acris (LK); Acrium (KR); Aculex (KR); Acurmil (JO); Atacure (JO, LB, QA); Atra (KR, TH); Atracor (PH); Atracurex (PH); Atradnor (EG); Atralex (MY); Atravell (PH); Atrium (BD, PH); Farelax (ID); Genso (TW); Intuban (UA); Notrixum (ID, MY, TH); Relaston (BD); Relatrac (CO, CR, DO, GT, HN, MX, NI, PA, PE, SV); Tarcum (PH); Trac (PH); Tracrium (AE, AR, AT, AU, BB, BD, BF, BG, BH, BJ, BM, BR, BS, BZ, CH, CI, CL, CN, CR, CY, CZ, DE, DK, EC, EE, EG, ES, ET, FI, FR, GB, GH, GM, GN, GR, GY, HK, HN, HU, ID, IE, IL, IN, IQ, IR, IT, JM, JO, JP, KE, KW, LB, LK, LR, LT, LU, LV, LY, MA, ML, MR, MT, MU, MW, MX, NE, NG, NL, NO, NZ, OM, PA, PH, PK, PL, PT, PY, QA, RO, RU, SA, SC, SD, SE, SG, SK, SL, SN, SR, SV, SY, TH, TN, TR, TT, TW, TZ, UA, UG, UY, VN, YE, ZA, ZM, ZW); Tracrrium (SI); Tracur (BR); Tracurix (AR, PY); Tramus (ID); Trarium (KR)

Last Updated 4/10/20