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j Children up to 1 month of age may be more sen-

Atracurium besylate sitive to the effects of atracurium.

No known effect on pain threshold or con-
(ah-trah- KYOUR -ee-um) sciousness; use only with adequate anesthesia.

Classification(s): Skeletal muscle relaxant, ADDITIONAL SIDE EFFECTS

nondepolarizing Most Common
Pregnancy Category: C Skin flushing, itching, wheezing, bronchial secre-
tions, hives, increased HR, increased mean arterial
RX: Tracrium Injection. pressure.
SEE ALSO NEUROMUSCULAR BLOCKING AGENTS. CV: Flushing, tachycardia, increased mean arterial
pressure. Dermatologic: Rash, urticaria, reaction
INDICATIONS/USES at injection site. Musculoskeletal: Prolonged
block, inadequate block. Respiratory: Dyspnea,
(1) Skeletal muscle relaxant during surgery. (2)
laryngospasm. Hypersensitivity: Allergic reac-
Adjunct to general anesthesia. (3) Assist in ET in-
tions. Other side effects may be due to histamine
tubation. Investigational: Treat seizures due to release and include flushing, erythema, wheezing,
drugs or electrically induced. urticaria, itching, bronchial secretions, BP and
HR changes.
Prevents acetylcholine effects by competing for Symptoms: Hypotension, enhanced pharmacologic
the cholinergic receptor at the motor end plate. effects. Treatment: CV support. Ensure airway
and ventilation. An anticholinesterase reversing
May also release histamine, leading to hypoten-
agent (e.g., neostigmine, edrophonium, pyrido-
stigmine) with an anticholinergic agent (e.g., atro-
Pharmacokinetics pine, glycopyrrolate) may be used.
Onset: Within 2 min. Peak effect: 12 min. Du-
ration: 2040 min with balanced anesthesia. Re- ADDITIONAL DRUG INTERACTIONS
covery from blockade under balanced anesthesia Acetylcholinesterase inhibitors / Muscle relaxation
begins about 2035 min after injection; recovery is inhibited and neuromuscular block is reversed
is usually 95% complete within 6070 min after Aminoglycosides / e Muscle relaxation
injection. t1/2: 20 min. Recovery occurs more rap- Corticosteroids / Prolonged weakness
Enflurane / e Muscle relaxation
idly than recovery from d-tubocurarine, metocu-
Halothane / e Muscle relaxation
rine, and pancuronium. Metabolized in the
Isoflurane / e Muscle relaxation
Lithium / e Muscle relaxation
Phenytoin / a Effect of atracurium
CONTRAINDICATIONS Procainamide / e Muscle relaxation
In clients with myasthenia gravis, Eaton-Lambert
Quinidine / e Muscle relaxation
syndrome, electrolyte disorders, bronchial asthma. Succinylcholine / e Onset and depth of muscle re-
SPECIAL CONCERNS Theophylline / a Effect of atracurium
Should be used only by those skilled in air- Trimethaphan / e Muscle relaxation
way management and respiratory support. Verapamil / e Muscle relaxation
Have equipment and personnel immediately
available for endotracheal intubation and
Injection: 10 mg/mL.
support for ventilation. Have anticholinester-
ase reversal drugs immediately available.
Use with caution during labor and delivery and IV BOLUS ONLY
when significant histamine release would be Intubation and maintenance of neuromuscular
dangerous (e.g., CV disease, asthma). blockade.
Safety and efficacy not determined during lacta- Adults and children over 2 years, ini-
tion. tial: 0.40.5 mg/kg as IV bolus;
maintenance: 0.080.1 mg/kg. The 3. Reduce initial dose to 0.250.35 mg/kg if
first maintenance dose is usually re- used with steady-state enflurane or isoflurane
quired 2045 min after the initial dose. (smaller reductions with halothane).
Give maintenance doses every 1525 4. Reduce dosage with myasthenia gravis or oth-
min under balanced anesthesia, slightly er neuromuscular diseases, electrolyte disor-
longer under isoflurane or enflurane an- ders, or carcinomatosis.
esthesia. 5. Maintenance doses by continuous infusion of
a diluted solution can be given to clients age
Following use of succinylcholine for intubation
2 to adulthood.
under balanced anesthesia.
6. Solutions containing 0.2 or 0.5 mg/mL can
Initial: 0.30.4 mg/kg; if using potent
be stored either under refrigeration or at room
inhalation anesthetics, further reduc-
temperature for 24 hr without significant loss
tions may be required.
of potency.
Use in neuromuscular disease, severe 7. To preserve potency, refrigerate the drug at
electrolyte disorders, or carcinomatosis. 28C (3646F).
Consider dosage reductions where po- 8. Infusion solutions should be used within 24
tentiation of neuromuscular blockade hours of preparation.
or difficulty with reversal have been
9. N
or 0.9% NaCl.
D5W/0.9% NaCl, D5W,

Use after steady-state enflurane or isoflurane 10. I Do not mix with alka-
line solutions, including LR injection.
anesthesia established.
0.250.35 mg/kg (about one third less ASSESSMENT
than the usual initial dose). 1. Note reasons for therapy, expected duration,
Use in infants 1 month to 2 years of age under other agents/therapies trialed.
halothane anesthesia. 2. Use peripheral nerve stimulator to assess neu-
0.30.4 mg/kg. More frequent mainte- romuscular response and recovery.
nance doses may be required. 3. Should only be used on short-term basis and
IV INFUSION in continuously monitored environment. Drug
Balanced anesthesia. blocks effect of acetylcholine at myoneural
IV infusion: 910 mcg/kg until the junction; prevents neuromuscular transmis-
level of neuromuscular blockade is rees- sion. Assess regularly for twitch response.
tablished; then, rate of infusion is ad- 4. Have anticholinesterase agent such as neo-
stigmine, edrophonium, or pyridostigmine, in
justed according to client needs (usually
conjunction with an anticholinergic agent such
59 mcg/kg/min although some clients
as atropine or glycopyrrolate available for re-
may require as little as 2 mcg/kg/min
and others as much as 15 mcg/kg/min).
5. Reassure once drug wears off may resume
For cardiopulmonary bypass surgery in which talking/moving.
hypothermia is induced. 6. Obtain baseline ECG, VS, electrolytes, renal
Reduce rate of infusion by 50%. and LFTs; monitor. May cause vagal stimula-
tion resulting in bradycardia, hypotension,
arrhythmias. IV atropine may be used for bra-
1. IM administration may cause tissue irritation. 1. During administration, client may be able to
2. j Use only by those skilled in airway man- see and hear things in the immediate environ-
agement and respiratory support. Equipment ment but will not be able to move or talk. Re-
and personnel must be available immediately solves once drug discontinued.
for intubation and support of ventilation. Have 2. Monitor breathing by ventilator and ensure
anticholinesterase reversal agents immediate- alarms set, protect eyes with patches or
ly available. 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