Atracurium Dosing
For rapid sequence induction in adults, use atracurium 0.75-1.0 mg/kg IV without priming, with 1.0 mg/kg providing superior intubating conditions within 60 seconds. For continuous infusion maintenance, start at 5-9 mcg/kg/min after initial bolus dosing.
Rapid Sequence Induction Dosing
Standard Adult Dosing
Alternative Priming Technique
If using divided dosing:
- Priming dose: 0.06 mg/kg given 3 minutes before intubation
- Intubating dose: 0.44 mg/kg at time of intubation 3
- This reduces onset time to 42 seconds versus 91 seconds with single bolus 3
Cardiovascular Compromise
- Reduce to 0.3-0.4 mg/kg given slowly over 1 minute in patients with:
- Significant cardiovascular disease
- History of severe anaphylactoid reactions or asthma (histamine release risk) 4
Continuous Infusion Dosing
Operating Room Maintenance
After initial bolus (0.3-0.5 mg/kg):
- Initial infusion rate: 9-10 mcg/kg/min to counteract spontaneous recovery
- Maintenance rate: 5-9 mcg/kg/min for 89-99% neuromuscular blockade 4
- Range: 2-15 mcg/kg/min depending on individual response 4
- First maintenance bolus typically needed 20-45 minutes after initial dose 4
ICU Maintenance
- Infusion rate: 11-13 mcg/kg/min (range 4.5-29.5 mcg/kg/min) 4
- Fixed rate of 1 mg/kg/hr provides effective paralysis in ARDS patients 5
- Monitor with train-of-four (TOF); maintain TOF count ≤3 5
Inhalational Anesthetic Adjustments
Reduce infusion rates by approximately one-third with:
- Enflurane or isoflurane (significant potentiation)
- Smaller reductions with halothane (20% potentiation only) 4
Special Population Adjustments
Renal or Hepatic Impairment
No dose adjustment required 6, 7, 8
- Atracurium undergoes organ-independent elimination via Hofmann degradation and ester hydrolysis
- Duration of blockade unaffected by renal or hepatic dysfunction 6
- Preferred agent in renal/hepatic failure over renally-excreted alternatives 7
Important caveat: Laudanosine (metabolite) accumulates in renal failure but rarely reaches toxic concentrations even with 72-hour infusions 5. Only one case report of seizure exists 6.
Elderly Patients
No dose reduction required for initial bolus 4
- Onset time unchanged despite potentially longer duration 7
- Standard intubating doses maintain effective concentrations 7
Pediatric Patients
Ages ≥2 years:
Infants (1 month to 2 years):
- Initial dose: 0.3-0.4 mg/kg under halothane anesthesia 4
- Maintenance doses required more frequently than adults 4
Neonates:
- Insufficient data for specific recommendations 4
Following Succinylcholine
- Dose: 0.3-0.4 mg/kg for adults under balanced anesthesia 4
- Allow recovery from succinylcholine before atracurium administration 4
- Further reductions needed with potent inhalation agents 4
Hypothermia (Cardiopulmonary Bypass)
Reduce infusion rate by approximately 50% during hypothermia (25-28°C) 4
Recovery Characteristics
- Time to 25% recovery: 49 minutes after single bolus 8
- Recovery index (25-75%): 12 minutes 8
- Full recovery (TOF >0.7): 31-96 minutes after stopping infusion (median 45 minutes) 5
- Recovery time does not increase with repeated dosing 8
Monitoring Requirements
- Use peripheral nerve stimulator to guide dosing and prevent overdosage 4
- Target TOF count ≤3 during paralysis 5
- Monitor for histamine release at higher doses (>0.5 mg/kg) 6
Critical Pitfalls
- Avoid in patients requiring rapid reversal - no specific reversal agent exists (unlike rocuronium/sugammadex)
- Histamine release risk increases with rapid bolus or doses >0.5 mg/kg; give slowly in at-risk patients 6, 4
- Laudanosine accumulation possible with prolonged infusions in renal failure, though clinical seizures extremely rare 6, 5
- Delayed awakening after prolonged infusions is normal; median recovery 45 minutes 5