atracurium

General

High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error.

Pronunciation:
a-tra-kyoor-ee-um

Trade Name(s)

• Tracrium

Ther. Class.
neuromuscular blocking agents-nondepolarizing

Indications

• Induction of skeletal muscle paralysis and facilitation of intubation after induction of anesthesia in surgical procedures.
• Facilitation of compliance during mechanical ventilation.

Action

Prevents neuromuscular transmission by blocking the effect of acetylcholine at the myoneural junction. Has no analgesic or anxiolytic properties.

Therapeutic Effect(s):

Skeletal muscle paralysis.

Pharmacokinetics

Absorption: Following IV administration, absorption is essentially complete.

Distribution: Distributes into extracellular space; crosses the placenta.

Metabolism and Excretion: Metabolized in plasma; <5% excreted unchanged in urine

Half-life: Infants: 20 min; Children: 17 min; Adults: 16 min;

TIME/ACTION PROFILE (neuromuscular blockade)

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity
• 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.

Potential Diagnoses

• Ineffective breathing pattern (Indications) 
• Impaired verbal communication (Side Effects) 
• Fear (Side Effects) 

Implementation

• 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.

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.