Note: Doses must be individualized due to interpatient variability, patient specific factors, and/or comorbidities (eg, severe trauma, burn injury) (Ref).
Endotracheal intubation: Note: Ensure adequate pain control and sedation prior to and during administration of neuromuscular blockade.
IV: 0.5 to 0.6 mg/kg once (Ref).
Mechanically ventilated patients in the ICU, neuromuscular blockade:
Note: Ensure adequate pain control and sedation prior to and during administration of neuromuscular blockade. May use to facilitate mechanical ventilation (eg, refractory moderate to severe acute respiratory distress syndrome; refractory, life-threatening status asthmaticus; or shivering from therapeutic hypothermia) (Ref). Refer to institutional protocols. Titration specifics may vary; a titration example is provided below.
Continuous infusion : IV: 0.4 to 0.6 mg/kg initial loading dose, followed by continuous infusion of 4 to 12 mcg/kg/minute; titrate every ~5 to 10 minutes based on clinical response and neuromuscular monitoring (eg, train-of-four); usual dosage range: 2 to 20 mcg/kg/minute (Ref).
Intermittent dose : IV: 0.4 to 0.6 mg/kg, followed by 0.08 to 0.1 mg/kg every ~15 to 25 minutes based on clinical response and neuromuscular monitoring (eg, train-of-four) (Ref).
Neuromuscular blockade during general anesthesia (adjunctive therapy):
Maintenance dosing: Note: Inhaled anesthetic agents (eg, desflurane, isoflurane, sevoflurane) prolong the duration of action of atracurium and may potentiate the neuromuscular blockade.
Continuous infusion : IV: 4 to 12 mcg/kg/minute as an initial continuous infusion; titrate as needed based on clinical response and neuromuscular monitoring (eg, train-of-four); usual dosage range: 2 to 15 mcg/kg/minute (Ref).
Intermittent dose : IV: 0.08 to 0.1 mg/kg every ~15 to 25-minute intervals as needed based on clinical response and neuromuscular monitoring (eg, train-of-four) (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
No dosage adjustment necessary.
No dosage adjustment necessary.
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]) (Ref). 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 (Ref).
Refer to adult dosing.
(For additional information see "Atracurium: Pediatric drug information")
Note: Ensure adequate pain control and sedation prior to and during administration of neuromuscular blockade. Dose to effect; doses must be individualized due to interpatient variability. Maintenance doses in infants and children may need to be administered with slightly greater frequency compared to adults. Dosing in obese patients should be calculated using ideal body weight (Ref):
Neuromuscular blockade:
ICU paralysis (eg, facilitate mechanical ventilation) (Ref):
Infants, Children, and Adolescents:
Initial bolus: IV: 0.3 to 0.6 mg/kg/dose; repeat additional doses as needed to maintain desired neuromuscular blockade or begin continuous infusion.
Continuous IV infusion: Initial: 5 to 12 mcg/kg/minute (0.3 to 0.7 mg/kg/hour); range: 5 to 40 mcg/kg/minute (0.3 to 2.4 mg/kg/hour).
Adjunct to surgical anesthesia:
Bolus doses:
Infants and Children <2 years: Initial: IV: 0.3 to 0.4 mg/kg once, followed by additional doses as needed to maintain neuromuscular blockade.
Children ≥2 years and Adolescents: IV: 0.4 to 0.5 mg/kg once as initial dose, then administer 0.08 to 0.1 mg/kg/dose 20 to 45 minutes after the initial dose to maintain neuromuscular blockade; repeat dose every 15 to 25 minutes as needed. Note: Initial dose should be reduced to 0.3 to 0.4 mg/kg in patients with significant cardiovascular disease or with history of increased risk of histamine release (eg, asthma, severe anaphylactoid reaction).
Continuous IV infusion in operating room during extended surgical procedures:
Infants and Children <2 years: Continuous IV infusion: Initial: 6 to 14 mcg/kg/minute (0.4 to 0.8 mg/kg/hour) initiated at the first signs of recovery from initial bolus; titrate until desired neuromuscular blockade is achieved (Ref).
Children ≥2 years and Adolescents: Continuous IV infusion: Initial: 9 to 10 mcg/kg/minute (0.5 to 0.6 mg/kg/hour), initiate infusion at initial signs of recovery from bolus dose, titrate until desired neuromuscular blockade is achieved; block is usually maintained by a rate of 5 to 9 mcg/kg/minute (0.3 to 0.5 mg/kg/hour); range: 2 to 15 mcg/kg/minute (0.1 to 0.9 mg/kg/hour).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Infants, Children, and Adolescents: No dosage adjustment necessary.
Infants, Children, and Adolescents: No dosage adjustment necessary.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. 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
Hypersensitivity to atracurium or any component of the formulation; known hypersensitivity to benzyl alcohol (multiple dose vials)
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.
• Prolonged paralysis: Some patients may experience prolonged recovery of neuromuscular function after administration (especially after prolonged use). Patients should be adequately recovered prior to extubation. Other factors associated with prolonged recovery should be considered (eg, corticosteroid use, patient condition).
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; Gropper 2019; 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; Gropper 2019; Naguib 2002).
Special populations:
• Older adults: Use with caution in older adults; 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.
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)
Yes
Solution (Atracurium Besylate Intravenous)
50 mg/5 mL (per mL): $1.14 - $1.90
100 mg/10 mL (per mL): $1.13 - $1.90
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.
IV: Administer undiluted as a bolus injection; do not administer IM (excessive tissue irritation). Continuous infusion administration requires the use of an infusion pump. Do not administer with alkaline solutions in the same syringe or simultaneously in the same IV line. Use infusion solutions within 24 hours of preparation.
Parenteral: For IV use only; do not administer IM due to tissue irritation.
IV bolus: Administer undiluted as IV bolus injection.
Continuous IV infusions: Further dilute in a compatible fluid and administer via an infusion pump.
IV infusion: 20 mg in 100 mL (concentration: 0.2 mg/mL) or 50 mg in 100 mL (concentration: 0.5 mg/mL) or 250 mg in 250 mL (concentration: 1 mg/mL) or 500 mg in 100 mL (concentration: 5 mg/mL) of D5W, D5NS, or NS.
Endotracheal intubation: To facilitate endotracheal intubation.
Mechanically ventilated patients in the ICU, neuromuscular blockade: Provide skeletal muscle relaxation during mechanical ventilation in ICU patients.
Neuromuscular blockade during general anesthesia: As an adjunct to general anesthesia to provide skeletal muscle relaxation during surgery.
Note: Neuromuscular blockade does not provide pain control, sedation, or amnestic effects. Ensure adequate pain control and sedation prior to and during administration of neuromuscular blockade (Ref).
The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes (neuromuscular blocker agent) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Acute Care Settings).
According to the 2020 to 2021 ISMP Targeted Medication Safety Best Practices for Hospitals, neuromuscular blockers should be segregated, sequestered, and differentiated from all other medication wherever they are stored. This includes:
Only storing in places within the hospital that they are routinely used.
Placing in sealed boxes or in rapid sequence intubation kits (preferred).
Limiting availability in automated dispensing cabinets to perioperative, labor and delivery, critical care, and emergency departments only.
Placing in separate lidded containers within the pharmacy refrigerator or other isolated pharmacy storage area.
Affixing an auxiliary label to clearly communicate respiratory paralysis will occur and ventilation required on all storage bins and/or automated dispensing pockets/drawers (exception anesthesia-prepared syringes) stating one of the following:
Warning: Causes Respiratory Arrest – Patient Must Be Ventilated
Warning: Paralyzing Agent – Causes Respiratory Arrest
Warning: Causes Respiratory Paralysis – Patient Must Be Ventilated
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
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). Specifically, this effect is observed with chronic phenytoin administration. Fosphenytoin-Phenytoin may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Specifically, this effects is observed with acute/short term phenytoin administration. 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. 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
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
Small amounts of atracurium have been shown to cross the placenta when given to women during cesarean section.
It is not known if atracurium is present in breast milk. The manufacturer recommends that caution be exercised when administering atracurium to breastfeeding women.
Vital signs (heart rate, blood pressure, respiratory rate); degree of muscle paralysis (eg, presence of spontaneous movement, ventilator asynchrony, shivering, and use a peripheral nerve stimulator with train of four monitoring along with clinical assessments).
In the ICU setting, limiting the duration of paralysis and providing a physiotherapy regimen in patients requiring continuous paralysis is suggested.
Blocks neural transmission at the myoneural junction by binding with cholinergic receptor sites
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 (Fisher 1990): Vd:
Infants: 0.21 ± 0.12 L/kg.
Children: 0.13 ± 0.04 L/kg.
Adults: 0.1 ± 0.02 L/kg.
Metabolism: Undergoes ester hydrolysis and Hofmann elimination (nonbiologic process independent of kidney, 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 ± 5.1 minutes (Fisher 1990).
Children: 17.2 ± 5.1 minutes (Fisher 1990).
Adults: Biphasic: Initial (distribution): 2 minutes; Terminal: 20 minutes.
Excretion: Urine (<5%).
Clearance (Fisher 1990):
Infants: 7.9 ± 0.2 mL/kg/minute.
Children: 6.8 ± 1.6 mL/kg/minute.
Adults: 5.3 ± 0.9 mL/kg/minute.
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