Atracurium Dosing Recommendations
For intubation in adults, administer atracurium 0.4-0.5 mg/kg IV bolus, which provides excellent intubating conditions in 2-2.5 minutes; for maintenance, use 0.08-0.10 mg/kg bolus doses every 15-25 minutes or a continuous infusion of 5-9 mcg/kg/min. 1
Adult Dosing
Intubation (Initial Bolus)
Standard dose: 0.4-0.5 mg/kg IV bolus 1
- Onset: 2-2.5 minutes to intubation
- Maximum block: 3-5 minutes
- Duration: 20-35 minutes under balanced anesthesia
Reduced dose scenarios (0.3-0.4 mg/kg): 1
- Significant cardiovascular disease (give slowly over 1 minute)
- History of severe anaphylactoid reactions or asthma
- Following succinylcholine use
- Under steady-state isoflurane or enflurane (reduce by one-third to 0.25-0.35 mg/kg)
Maintenance Dosing
Intermittent bolus approach: 1
- 0.08-0.10 mg/kg every 15-25 minutes under balanced anesthesia
- First maintenance dose typically needed 20-45 minutes after initial dose
- Higher doses (up to 0.2 mg/kg) allow longer dosing intervals
Continuous infusion approach: 1
- Initial rate: 9-10 mcg/kg/min to counteract spontaneous recovery
- Maintenance rate: 5-9 mcg/kg/min (range 2-15 mcg/kg/min)
- Start infusion only after early evidence of spontaneous recovery from bolus
- Reduce by one-third under steady-state enflurane/isoflurane
Pediatric Dosing
Children ≥2 Years
- No dose adjustment required - use adult dosing 1
- Maintenance doses may be required slightly more frequently than adults 1
Infants (1 Month to 2 Years)
- Initial dose: 0.3-0.4 mg/kg under halothane anesthesia 1
- Maintenance doses required more frequently than adults 1
- Infusion requirement: 0.53 mg/kg/hr for children >1 month 2
Neonates (<1 Month)
- Reduced requirement: 0.40 mg/kg/hr (25% less than older children) 2
Elderly Patients
No dose adjustment required - elderly patients (mean age 76 years) required similar doses to younger adults (14.7-15 mg/m²/hr) with comparable recovery times 3. However, consider reduced initial doses (0.3-0.4 mg/kg) if significant cardiovascular disease is present 1.
Critical Care/ICU Dosing
For sustained neuromuscular blockade in critically ill adults, atracurium can be used via continuous infusion, though cisatracurium is increasingly preferred due to less histamine release and fewer cardiovascular effects 4. When atracurium is used in the ICU setting, infusion rates of 2-20 mcg/kg/min have been described 5.
Important Clinical Considerations
Advantages in Special Populations
- Renal/hepatic failure: No dose adjustment needed - atracurium undergoes organ-independent elimination (Hofmann elimination and ester hydrolysis) 6, 1
- Duration of blockade unaffected by renal or hepatic dysfunction 4
Key Warnings
- Histamine release: Can occur at higher doses, causing cardiovascular effects 4
- Laudanosine accumulation: Theoretical seizure risk with extremely high doses or hepatic failure, though only one case report exists 4
- Never give intramuscularly - causes tissue irritation 1
- Avoid mixing with alkaline solutions (e.g., barbiturates) 1
Monitoring
Use peripheral nerve stimulator to optimize dosing and minimize over/underdosing 1. Target train-of-four (TOF) monitoring to guide maintenance dosing.
Anesthetic Interactions
Potentiation occurs with volatile anesthetics - reduce doses accordingly: