j Children up to 1 month of age may be more sen-
Atracurium besylate
(ah-trah- KYOUR -ee-um)
Classification(s): Skeletal muscle relaxant,
nondepolarizing
Pregnancy Category: C
RX: Tracrium Injection.
SEE ALSO NEUROMUSCULAR BLOCKING AGENTS.
INDICATIONS/USES
(1) Skeletal muscle relaxant during surgery. (2)
Adjunct to general anesthesia. (3) Assist in ET in-
tubation. Investigational: Treat seizures due to
drugs or electrically induced.
ACTION/KINETICS
Action
Prevents acetylcholine effects by competing for
the cholinergic receptor at the motor end plate.
May also release histamine, leading to hypoten-
sion.
Pharmacokinetics
Onset: Within 2 min. Peak effect: 12 min. Du-
ration: 2040 min with balanced anesthesia. Re-
covery from blockade under balanced anesthesia
begins about 2035 min after injection; recovery
is usually 95% complete within 6070 min after
injection. t1/2: 20 min. Recovery occurs more rap-
idly than recovery from d-tubocurarine, metocu-
rine, and pancuronium. Metabolized in the
plasma.
CONTRAINDICATIONS
In clients with myasthenia gravis, Eaton-Lambert
syndrome, electrolyte disorders, bronchial asthma.
SPECIAL CONCERNS
Should be used only by those skilled in air-
way management and respiratory support.
Have equipment and personnel immediately
available for endotracheal intubation and
support for ventilation. Have anticholinester-
ase reversal drugs immediately available.
Use with caution during labor and delivery and
when significant histamine release would be
dangerous (e.g., CV disease, asthma).
Safety and efficacy not determined during lacta-
tion.
sitive to the effects of atracurium.
No known effect on pain threshold or con-
sciousness; use only with adequate anesthesia.
ADDITIONAL SIDE EFFECTS
Most Common
Skin flushing, itching, wheezing, bronchial secre-
tions, hives, increased HR, increased mean arterial
pressure.
CV: Flushing, tachycardia, increased mean arterial
pressure. Dermatologic: Rash, urticaria, reaction
at injection site. Musculoskeletal: Prolonged
block, inadequate block. Respiratory: Dyspnea,
laryngospasm. Hypersensitivity: Allergic reac-
tions. Other side effects may be due to histamine
release and include flushing, erythema, wheezing,
urticaria, itching, bronchial secretions, BP and
HR changes.
OVERDOSE MANAGEMENT
Symptoms: Hypotension, enhanced pharmacologic
effects. Treatment: CV support. Ensure airway
and ventilation. An anticholinesterase reversing
agent (e.g., neostigmine, edrophonium, pyrido-
stigmine) with an anticholinergic agent (e.g., atro-
pine, glycopyrrolate) may be used.
ADDITIONAL DRUG INTERACTIONS
Acetylcholinesterase inhibitors / Muscle relaxation
is inhibited and neuromuscular block is reversed
Aminoglycosides / e Muscle relaxation
Corticosteroids / Prolonged weakness
Enflurane / e Muscle relaxation
Halothane / e Muscle relaxation
Isoflurane / e Muscle relaxation
Lithium / e Muscle relaxation
Phenytoin / a Effect of atracurium
Procainamide / e Muscle relaxation
Quinidine / e Muscle relaxation
Succinylcholine / e Onset and depth of muscle re-
laxation
Theophylline / a Effect of atracurium
Trimethaphan / e Muscle relaxation
Verapamil / e Muscle relaxation
HOW SUPPLIED
Injection: 10 mg/mL.
DOSAGE
IV BOLUS ONLY
Intubation and maintenance of neuromuscular
blockade.
Adults and children over 2 years, ini-
tial: 0.40.5 mg/kg as IV bolus;
 maintenance: 0.080.1 mg/kg. The
first maintenance dose is usually re-
quired 2045 min after the initial dose.
Give maintenance doses every 1525
min under balanced anesthesia, slightly
longer under isoflurane or enflurane an-
esthesia.
Following use of succinylcholine for intubation
under balanced anesthesia.
Initial: 0.30.4 mg/kg; if using potent
inhalation anesthetics, further reduc-
tions may be required.
Use in neuromuscular disease, severe
electrolyte disorders, or carcinomatosis.
Consider dosage reductions where po-
tentiation of neuromuscular blockade
or difficulty with reversal have been
noted.
Use after steady-state enflurane or isoflurane
anesthesia established.
0.250.35 mg/kg (about one third less
than the usual initial dose).
Use in infants 1 month to 2 years of age under
halothane anesthesia.
0.30.4 mg/kg. More frequent mainte-
nance doses may be required.
IV INFUSION
Balanced anesthesia.
IV infusion: 910 mcg/kg until the
level of neuromuscular blockade is rees-
tablished; then, rate of infusion is ad-
justed according to client needs (usually
59 mcg/kg/min although some clients
may require as little as 2 mcg/kg/min
and others as much as 15 mcg/kg/min).
For cardiopulmonary bypass surgery in which
hypothermia is induced.
Reduce rate of infusion by 50%.
NURSING IMPLICATIONS
IMPLEMENTATION/ADMINISTRATION/STORAGE
1. IM administration may cause tissue irritation.
2. j Use only by those skilled in airway man-
agement and respiratory support. Equipment
and personnel must be available immediately
for intubation and support of ventilation. Have
anticholinesterase reversal agents immediate-
ly available.
3. Reduce initial dose to 0.250.35 mg/kg if
used with steady-state enflurane or isoflurane
(smaller reductions with halothane).
4. Reduce dosage with myasthenia gravis or oth-
er neuromuscular diseases, electrolyte disor-
ders, or carcinomatosis.
5. Maintenance doses by continuous infusion of
a diluted solution can be given to clients age
2 to adulthood.
6. Solutions containing 0.2 or 0.5 mg/mL can
be stored either under refrigeration or at room
temperature for 24 hr without significant loss
of potency.
7. To preserve potency, refrigerate the drug at
28C (3646F).
8. Infusion solutions should be used within 24
hours of preparation.
9. N
or 0.9% NaCl.
D5W/0.9% NaCl, D5W,
10. I Do not mix with alka-
line solutions, including LR injection.
ASSESSMENT
1. Note reasons for therapy, expected duration,
other agents/therapies trialed.
2. Use peripheral nerve stimulator to assess neu-
romuscular response and recovery.
3. Should only be used on short-term basis and
in continuously monitored environment. Drug
blocks effect of acetylcholine at myoneural
junction; prevents neuromuscular transmis-
sion. Assess regularly for twitch response.
4. Have anticholinesterase agent such as neo-
stigmine, edrophonium, or pyridostigmine, in
conjunction with an anticholinergic agent such
as atropine or glycopyrrolate available for re-
versal.
5. Reassure once drug wears off may resume
talking/moving.
6. Obtain baseline ECG, VS, electrolytes, renal
and LFTs; monitor. May cause vagal stimula-
tion resulting in bradycardia, hypotension,
arrhythmias. IV atropine may be used for bra-
dycardia.
CLIENT/FAMILY TEACHING
1. During administration, client may be able to
see and hear things in the immediate environ-
ment but will not be able to move or talk. Re-
solves once drug discontinued.
2. Monitor breathing by ventilator and ensure
alarms set, protect eyes with patches or
drops.
3. May be fully conscious, aware of surroundings OUTCOMES/EVALUATE
and conversations. Drug does not affect pain Skeletal muscle paralysis
threshold or anxiety; will need analgesics/an- Facilitation of ET intubation; tolerance of me-
tianxiety agents regularly. chanical ventilation
4. Once drug stopped all movement, breathing Control of electrically/pharmacologically induced
and talking will return. seizures