Pedi: Products containing benzyl alcohol should be avoided in neonates.
Use Cautiously in:
Dehydration or electrolyte abnormalities (should be corrected before administration)
Situations in which histamine release would be problematic
Fractures or muscle spasm
Hyperthermia (↑ duration/intensity of paralysis)
Shock
Extensive burns (may be more resistant to effects)
Low plasma pseudocholinesterase levels (may be seen in association with anemia, dehydration, cholinesterase inhibitors/insecticides, severe liver disease, pregnancy, or hereditary predisposition)
Obesity
OB: Use during pregnancy only if potential maternal benefits justify potential fetal risk;
Lactation: Safety not established in breastfeeding;
Pedi: Children <1 mo (safety and effectiveness not established).
Exercise Extreme Caution in:
Neuromuscular diseases such as myasthenia gravis (small test dose may be used to assess response).
IV (Adults and Children >2 yr): 0.4–0.5 mg/kg initially (0.25–0.35 mg/kg if administered after steady-state anesthesia with enflurane or isoflurane or 0.3–0.4 mg/kg following succinylcholine); may then repeat with 0.08–0.1 mg/kg 20–45 min after initial dose, as needed, or by continuous infusion at 5–9 mcg/kg/min.
IV (Neonates , Infants, and Children 1 mo–2 yr): 0.3–0.4 mg/kg initially, followed by maintenance doses of 0.3–0.4 mg/kg as needed.
Assess ECG, HR, BP, and respiratory status continuously throughout therapy. Use atracurium only to facilitate or maintain intubation.
Monitor neuromuscular response with a peripheral nerve stimulator intraoperatively. Paralysis is initially selective and usually occurs sequentially in the following muscles: levator muscles of eyelids, muscles of mastication, limb muscles, abdominal muscles, muscles of the glottis, intercostal muscles, and the diaphragm. Recovery of muscle function usually occurs in reverse order.
Monitor for signs/symptoms of anaphylaxis. If reaction occurs, immediately discontinue atracurium and treat as indicated. Keep emergency medications and equipment available for immediate use.
Assess for residual muscle weakness and respiratory distress during recovery period.
Pedi: Assess for respiratory depression in neonate exposed to atracurium during cesarean section.
Monitor infusion site frequently. If tissue irritation or extravasation occurs, discontinue and restart in another vein.
Toxicity and Overdose:
If overdose occurs, use peripheral nerve stimulator to determine the degree of neuromuscular blockade. Maintain airway patency and ventilation until recovery occurs.
May administer of anticholinesterase agent (neostigmine, pyridostigmine) as antidote once some spontaneous recovery from neuromuscular block has occurred. Atropine is usually administered prior to or concurrently with anticholinesterase agents to counteract the muscarinic effects.
High Alert: Unplanned administration of a neuromuscular blocking agent instead of administration of the intended medication or administration of a neuromuscular blocking agent in the absence of ventilatory support has resulted in serious harm and death. Confusing similarities in packaging and insufficiently controlled access to these medications are often implicated in these medication errors.
Dose is titrated to patient response.
Atracurium has no effect on consciousness or pain threshold. Adequate anesthesia/analgesia should always be used when neuromuscular blocking agents are administered. Benzodiazepines and/or analgesics should be administered concurrently with prolonged neuromuscular blocker therapy.
If eyes remain open throughout prolonged administration, protect corneas with artificial tears.
Advise patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care provider before taking other medications.
Explain all procedures to patient receiving atracurium therapy without general anesthesia, because consciousness is not affected by atracurium alone.
Reassure patient that communication abilities will return.
Rep: Advise women of reproductive potential to notify health care provider if pregnancy is suspected or if breastfeeding.