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: IV administration results in complete bioavailability.

Distribution: Distributes into extracellular space.

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 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).

Adverse Reactions/Side Effects

CV: hypotension, tachycardia

Derm: flushing, rash

Resp: bronchospasm

Misc: HYPERSENSITIVITY 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,  clindamycin,  lidocaine, other  local anesthetics,  lithium,  quinidine,  procainamide,  beta blockers,  thiazide diuretics,  loop 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 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.

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.

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 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.

Patient/Family Teaching

• Explain purpose and side effects of medication.
• 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.

Evaluation/Desired Outcomes

• Adequate suppression of the twitch response when tested with peripheral nerve stimulation and subsequent muscle paralysis.
• Improved compliance during mechanical ventilation.