What is the recommended intravenous pediatric dose of atracurium?

Atracurium Pediatric Dosing

The recommended intravenous dose of atracurium for pediatric patients is 0.3-0.4 mg/kg for infants (1 month to 2 years) and 0.4-0.5 mg/kg for children ≥2 years of age for intubation, with maintenance doses of 0.08-0.10 mg/kg. 1

Initial Dosing by Age Group

Infants (1 month to 2 years)

• Initial dose: 0.3-0.4 mg/kg IV under halothane anesthesia 1
• Onset to adequate intubation conditions: 60-90 seconds 2
• Duration of action: approximately 30-45 minutes 2
• Important caveat: Neonates and infants are more sensitive to atracurium and require lower doses than older children to achieve the same degree of neuromuscular blockade 3

Children ≥2 years

• Initial dose: 0.4-0.5 mg/kg IV (1.7-2.2 times ED95) 1
• No dosage adjustments required compared to adults 1
• Good to excellent intubation conditions expected in 2-2.5 minutes 1
• Maximum neuromuscular block achieved at 3-5 minutes 1

Maintenance Dosing

Maintenance doses: 0.08-0.10 mg/kg IV 1

• First maintenance dose typically required 20-45 minutes after initial dose 1
• Maintenance doses may be required with slightly greater frequency in infants and children than in adults 1
• Dosing intervals: approximately 15-25 minutes under balanced anesthesia 1

Continuous Infusion (for children ≥2 years)

After initial bolus dose:

• Initial infusion rate: 9-10 mcg/kg/min to rapidly counteract spontaneous recovery 1
• Maintenance infusion rate: 5-9 mcg/kg/min for most pediatric patients under balanced anesthesia 1
• Range: 2-15 mcg/kg/min depending on individual response 1
• Critical note: Limited data suggest pediatric ICU patients may require higher infusion rates than adults 1

Dose Modifications Based on Anesthetic Agent

With Volatile Anesthetics

The neuromuscular blocking effect of atracurium is potentiated by inhalation anesthetics 1:

• Isoflurane or enflurane: Reduce initial dose by approximately one-third (to 0.25-0.35 mg/kg) if administered under steady-state anesthesia 1
• Halothane: Consider smaller dosage reductions (approximately 20% potentiation effect) 1
• Infusion rates: Reduce by approximately one-third with enflurane/isoflurane; smaller reductions with halothane 1

Special Considerations

High-Risk Patients

For children with cardiovascular disease, asthma, or history of severe anaphylactoid reactions: 0.3-0.4 mg/kg given slowly or in divided doses over one minute 1

This reduced dose minimizes histamine release risk while maintaining adequate neuromuscular blockade.

Following Succinylcholine

• Insufficient data for specific pediatric dosing recommendations 1
• In adults, 0.3-0.4 mg/kg is recommended; allow recovery from succinylcholine effects first 1

Renal/Hepatic Failure

• No dosage adjustments required for initial or maintenance doses 1
• Atracurium undergoes organ-independent Hofmann elimination 4

Critical Safety Points

Mandatory Requirements

• Atracurium provides NO sedation, analgesia, or amnesia 2
• Do NOT administer before unconsciousness is induced 1
• Ventilatory support is mandatory 2
• Personnel skilled in airway management must be present with age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation immediately available 2

Administration Route

• Administer ONLY intravenously 1
• DO NOT give intramuscularly - may cause tissue irritation 1
• Do not mix with alkaline solutions (e.g., barbiturates) 1

Monitoring

Use of a peripheral nerve stimulator is strongly recommended to:

• Minimize overdosage or underdosage risk
• Assist in evaluation of recovery
• Optimize atracurium use 1

Clinical Pearls

Age-related sensitivity: Research demonstrates that neonates and infants have significantly lower ED50 values (82 and 112 mcg/kg respectively) compared to children (135 mcg/kg), confirming increased sensitivity in younger patients 3. However, recovery is actually more rapid in neonates (22.7 minutes to 10% recovery vs. 29.7 minutes in older children) 3.

Lower dose alternatives: Studies show that reduced doses of 0.25-0.3 mg/kg can provide good intubating conditions in children under halothane anesthesia, with intubation times of 2.2-2.6 minutes versus 1.5 minutes with 0.4 mg/kg 5. This may be useful for shorter procedures (20-30 minutes) where rapid recovery is desired.

Residual blockade risk: While atracurium lacks cumulative effects, approximately 8% of young children may have residual neuromuscular blockade (TOF ratio <0.9) at conclusion of surgery, particularly with volatile anesthetics 6. This underscores the importance of objective neuromuscular monitoring.