Atracurium Besylate for Endotracheal Intubation and Skeletal Muscle Relaxation
Atracurium besylate is recommended at a dose of 0.4 to 0.5 mg/kg intravenously for endotracheal intubation, with maintenance doses of 0.08 to 0.10 mg/kg administered every 15-25 minutes as needed for prolonged skeletal muscle relaxation. 1
Dosing Recommendations
Initial Dosing for Intubation
- Adults: 0.4 to 0.5 mg/kg IV (1.7 to 2.2 times the ED95) 1
- Onset of action: 2 to 2.5 minutes
- Maximum neuromuscular block: 3 to 5 minutes
- Duration of clinical effect: 20 to 35 minutes under balanced anesthesia
- Pediatric patients:
- Children ≥2 years: Same as adults
- Infants (1 month to 2 years): 0.3 to 0.4 mg/kg under halothane anesthesia 1
- Special populations:
- Patients with cardiovascular disease: 0.3 to 0.4 mg/kg (given slowly or in divided doses over one minute) 1
Maintenance Dosing
- 0.08 to 0.10 mg/kg IV for continued muscle relaxation 1
- First maintenance dose typically needed 20-45 minutes after initial dose
- Subsequent doses every 15-25 minutes under balanced anesthesia 1
- Higher doses (up to 0.2 mg/kg) allow for longer intervals between maintenance doses
Anesthetic Considerations
Potentiation by Inhalation Anesthetics
- Isoflurane and enflurane increase potency by approximately 35% 1
- Reduce initial dose to 0.25-0.35 mg/kg when administered under steady-state conditions of these agents
- Halothane has marginal potentiating effect (approximately 20%) 1
- Smaller dosage reductions may be considered
Monitoring
- Peripheral nerve stimulation monitoring is strongly recommended to:
- If instrumental monitoring is used, the corrugator supercilii muscle is recommended as the monitoring site due to its sensitivity to muscle relaxants and comparable kinetics to laryngeal muscles 2
Clinical Applications
Endotracheal Intubation
- Atracurium provides good to excellent intubation conditions in over 90% of patients 3, 4
- Should not be administered before unconsciousness has been induced 1
- Recommended for routine intubation when a non-depolarizing agent is preferred
Skeletal Muscle Relaxation for Surgical Procedures
- Strongly recommended for abdominal laparotomy and laparoscopic procedures 2
- Recommended for ENT laser surgery 2
- Provides adequate muscle relaxation for approximately 40 minutes after initial dose 4
Management of Airway Complications
- Low doses (0.1-0.2 mg/kg) may be effective for managing glottic closure if anesthesia depth is adequate 2
- Can be used for airway obstruction related to supraglottic device placement 2
Recovery and Reversal
- Recovery to 25% of control: 35-45 minutes after initial dose 1
- Recovery 95% complete: approximately 60 minutes after injection 1
- Can be reversed with anticholinesterase agents (neostigmine, edrophonium, pyridostigmine) in conjunction with anticholinergic agents 1
- Reversal can usually be attempted 20-35 minutes after initial dose when recovery of muscle twitch has started 1
Important Precautions
- DO NOT ADMINISTER INTRAMUSCULARLY 1
- Do not mix with alkaline solutions (e.g., barbiturate solutions) in the same syringe or administer through the same needle 1
- Unlike some other neuromuscular blocking agents, atracurium's duration is not affected by renal function or plasma pseudocholinesterase levels 1
- Minimal histamine release at recommended doses 1
- Metabolized via two non-oxidative pathways: ester hydrolysis and Hofmann elimination 1
Monitoring During Use
- Intraoperative monitoring of neuromuscular blockade is strongly recommended 2
- Helps determine optimal timing for maintenance doses
- Guides appropriate timing for reversal agents
- Reduces risk of residual neuromuscular blockade
Atracurium provides a favorable profile for both intubation and surgical muscle relaxation with predictable onset, duration, and recovery characteristics when used at recommended doses.