Pedi: Products containing benzyl alcohol should be avoided in neonates.
Use Cautiously in:
Dehydration or electrolyte abnormalities (should be corrected)
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)
Obese patients
OB: Lactation: Safety not established (use only if benefit outweighs potential risk to fetus)
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).
Adverse Reactions/Side Effects
Resp: bronchospasm
CV: hypotension, tachycardia
Derm: flushing, rash
Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS
* CAPITALS indicate life-threatening. Underline indicate most frequent.
Interactions
Drug-Drug
Intensity and duration of paralysis may be prolonged by pretreatment with succinylcholine, general anesthesia (inhalation), aminoglycosides, vancomycin, tetracyclines, polymyxin B, colistin, clindamycin, lidocaine, and other local anesthetics, lithium, quinidine, procainamide, beta-adrenergic blocking agents, potassium-losing diuretics, or magnesium.
Higher infusion rates may be required and duration of action may be shortened in patients receiving long-term carbamazepine or phenytoin.
Route/Dosage
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.
Availability (generic available)
Solution for injection: 10 mg/mL
Assessment
Assess respiratory status continuously throughout therapy with atracurium. Use only to facilitate intubation or in patients already intubated.
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 ECG, heart rate, and BP throughout administration.
Observe the patient for residual muscle weakness and respiratory distress during the recovery period.
Monitor infusion site frequently. If signs of tissue irritation or extravasation occur, discontinue and restart in another vein.
Toxicity Overdose: If overdose occurs, use peripheral nerve stimulator to determine the degree of neuromuscular blockade. Maintain airway patency and ventilation until recovery of normal respirations occurs.
Administration of anticholinesterase agents (neostigmine, pyridostigmine) may be used to antagonize the action of atracurium once the patient has demonstrated some spontaneous recovery from neuromuscular block. Atropine is usually administered prior to or concurrently with anticholinesterase agents to counteract the muscarinic effects.
Administration of fluids and vasopressors may be necessary to treat severe hypotension or shock.
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 used as an adjunct to surgical procedures or when painful procedures are performed. Benzodiazepines and/or analgesics should be administered concurrently when prolonged neuromuscular blocker therapy is used for ventilator patients, because patient is awake and able to feel all sensations.
If eyes remain open throughout prolonged administration, protect corneas with artificial tears.
Store atracurium in refrigerator.
Most neuromuscular blocking agents are incompatible with barbiturates and sodium bicarbonate. Do not admix.
IV Administration
IV Push: May be administered undiluted.
Rate: Administer initial IV dose as a bolus over 1 min.
Intermittent Infusion: Maintenance dose is usually required 20–45 min following initial dose.
Diluent: D5W, 0.9% NaCl, or D5/0.9% NaCl.Administer every 15–25 min or by continuous infusion.
Continuous Infusion: Maintenance dose is administered by infusion. Concentration: 0.5 mg/mL for continuous infusion.
Rate: Titrate according to patient response.
Syringe Compatibility
alfentanil
fentanyl
midazolam
sufentanil
Y-Site Compatibility
acyclovir
alemtuzumab
alfentanil
amikacin
amiodarone
amphotericin B lipid complex
anidulafungin
argatroban
ascorbic acid
atropine
azathioprine
azithromycin
aztreonam
benztropine
bivalirudin
bleomycin
bumetanide
buprenorphine
butorphanol
calcium chloride
calcium gluconate
carboplatin
caspofungin
cefazolin
cefotaxime
cefoxitin
ceftriaxone
cefuroxime
chloramphenicol
chlorpromazine
cisplatin
clindamycin
cyanocobalamin
cyclophosphamide
cyclosporine
cytarabine
dactinomycin
daptomycin
dexamethasone
dexmedetomidine
dexrazoxane
digoxin
diltiazem
diphenhydramine
dobutamine
docetaxel
dopamine
doxorubicin hydrochloride liposome
doxycycline
enalaprilat
ephedrine
epinephrine
epirubicin
epoetin
eptifibatide
ertapenem
erythromycin
esmolol
etomidate
etoposide
etoposide phosphate
famotidine
fenoldopam
fentanyl
fluconazole
fludarabine
fluorouracil
folic acid
foscarnet
gemcitabine
gentamicin
glycopyrrolate
granisetron
hetastarch
hydrocortisone sodium succinate
hydromorphone
idarubicin
ifosfamide
imipenem/cilastatin
irinotecan
isoproterenol
ketorolac
labetalol
leucovorin
levofloxacin
lidocaine
linezolid
lorazepam
magnesium sulfate
mannitol
meperidine
metaraminol
methotrexate
methyldopate
methylprednisolone
metoclopramide
metoprolol
metronidazole
midazolam
milrinone
minocycline
mitoxantrone
morphine
multivitamins
mycophenolate
nafcillin
nalbuphine
naloxone
nicardipine
nitroglycerin
norepinephrine
octreotide
ondansetron
oxacillin
oxaliplatin
oxytocin
paclitaxel
palonosetron
pamidronate
papaverine
pemetrexed
penicillin G
pentamidine
phentolamine
phenylephrine
phytonadione
potassium acetate
potassium chloride
procainamide
prochlorperazine
promethazine
propranolol
protamine
pyridoxime
quinupristin/dalfopristin
ranitidine
sodium acetate
streptokinase
succinylcholine
sufentanil
tacrolimus
teniposide
theophylline
thiamine
thiotepa
tigecycline
tirofiban
tobramycin
tolazoline
vancomycin
vasopressin
verapamil
vincristine
vinorelbine
zoledronic acid
Y-Site Incompatibility
aminophylline
amphotericin B deoxycholate
ceftazidime
dantrolene
diazepam
diazoxide
furosemide
ganciclovir
indomethacin
pantoprazole
pentobarbital
phenobarbital
phenytoin
sodium bicarbonate
thiopental
Patient/Family Teaching
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 as the medication wears off.
Evaluation/Desired Outcomes
Adequate suppression of the twitch response when tested with peripheral nerve stimulation and subsequent muscle paralysis.
Improved compliance during mechanical ventilation.
atracurium is a sample topic from the Davis's Drug Guide.
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