pleasure [5%):<2 years: Initial: 0.3 to 0.4 mg/kg followed by maintenance doses as needed to maintain neuromuscular blockade. Note: Maintenance doses in infants and children may need to be administered with slightly greater frequency compared to adults. Children 2 years and Adolescents: 0.4 to 0.5 mg/kg, then 0.08 to 0.1 mg/kg administered 20 to 45 minutes after initial dose to maintain neuromuscular block; repeat dose at 15- to 25-minute intervals as needed. Note: Initial dose may be reduced to 0.3 to 0.4 mg/kg in patients with significant cardiovascular disease or history of elevated risk of histamine release (eg, severe anaphylactoid reactions or asthma). Maintenance infusion for continued surgical relaxation during extended surgical procedures: Children 2 years and Adolescents: At initial signs of recovery from bolus dose, a continuous infusion may be initiated at a rate of 9 to 10 mcg /kg/ minute (0.54 to 0.6 mg /kg/ hour ); block usually maintained by a rate of 5 to 9 mcg /kg/ minute (0.3 to 0.54 mg /kg/ hour ) under balanced anesthesia; range: 2 to 15 mcg /kg/ minute (0.12 to 0.9 mg /kg/ hour ) Dosing: Renal Impairment No dosage adjustment necessary. Dosing: Hepatic Impairment No dosage adjustment necessary. Dosing: Obesity Morbidly-obese patients should be dosed using ideal body weight or an adjusted body weight (ie, between IBW and total body weight [TBW]) (Erstad 2004). In a bariatric surgical population of morbidly-obese patients who were administered an induction dose of atracurium based on TBW as compared to IBW, time to recovery of twitch response was prolonged (Kralingen 2011). Reconstitution May prepare an infusion solution (final concentrations: 0.2 mg/mL or 0.5 mg/mL) by admixing with an appropriate diluent (eg, NS, D 5 W, D 5 NS). Do not mix with alkaline solutions. Administration May be given undiluted as a bolus injection; do not administer IM (excessive tissue irritation). May also administer via continuous infusion; requires the use of an infusion pump. Use infusion solutions within 24 hours of preparation. Storage Store intact vials at 2 C to 8 C (36 F to 46 F). Do not freeze. Upon removal from refrigeration to room temperature storage conditions (25 C/77 F), use within 14 days even if re-refrigerated. Dilutions of 0.2 mg/mL or 0.5 mg/mL in 0.9% sodium chloride, dextrose 5% in water, or 5% dextrose in sodium chloride 0.9% are stable for up to 24 hours at room temperature or under refrigeration. Drug Interactions AbobotulinumtoxinA: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy Acetylcholinesterase Inhibitors: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Monitor therapy Amifampridine: Neuromuscular-Blocking Agents may diminish the therapeutic effect of Amifampridine. Amifampridine may diminish the therapeutic effect of Neuromuscular-Blocking Agents. Monitor therapy Aminoglycosides: May enhance the respiratory depressant effect of Neuromuscular-Blocking Agents. Monitor therapy Bacitracin (Systemic): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy Calcium Channel Blockers: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Monitor therapy Capreomycin: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy CarBAMazepine: May decrease the serum concentration of Neuromuscular-Blocking Agents (Nondepolarizing). Monitor therapy Cardiac Glycosides: Neuromuscular-Blocking Agents may enhance the arrhythmogenic effect of Cardiac Glycosides. Monitor therapy Clindamycin (Topical): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy Colistimethate: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Consider therapy modification Corticosteroids (Systemic): Neuromuscular-Blocking Agents (Nondepolarizing) may enhance the adverse neuromuscular effect of Corticosteroids (Systemic). Increased muscle weakness, possibly progressing to polyneuropathies and myopathies, may occur. Consider therapy modification CycloSPORINE (Systemic): May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy Fosphenytoin-Phenytoin: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Fosphenytoin-Phenytoin may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Fosphenytoin-Phenytoin may decrease the serum concentration of Neuromuscular-Blocking Agents (Nondepolarizing). Monitor therapy Inhalational Anesthetics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Monitor therapy Ketorolac (Nasal): May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents (Nondepolarizing). Specifically, episodes of apnea have been reported in patients using this combination. Monitor therapy Ketorolac (Systemic): May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents (Nondepolarizing). Specifically, episodes of apnea have been reported in patients using this combination. Monitor therapy Lincosamide Antibiotics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy Lithium: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy Local Anesthetics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Exceptions: Benzocaine; Benzydamine; Cocaine; Dibucaine; Dyclonine; Ethyl Chloride; Hexylresorcinol; Lidocaine (Ophthalmic); Lidocaine (Topical); Pramoxine; Proparacaine; Tetracaine (Ophthalmic); Tetracaine (Topical). Monitor therapy Loop Diuretics: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Loop Diuretics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy Magnesium Salts: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy Minocycline: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy OnabotulinumtoxinA: Neuromuscular-Blocking Agents may enhance the neuromuscular-blocking effect of OnabotulinumtoxinA. Monitor therapy Pholcodine: May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents. Specifically, anaphylaxis has been reported. Monitor therapy Polymyxin B: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Consider therapy modification Procainamide: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy QuiNIDine: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy QuiNINE: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Avoid combination RimabotulinumtoxinB: Neuromuscular-Blocking Agents may enhance the neuromuscular-blocking effect of RimabotulinumtoxinB. Monitor therapy Spironolactone: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Monitor therapy Tetracyclines: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy Trimebutine: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Monitor therapy Vancomycin: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Monitor therapy Adverse Reactions Frequency not defined. Adverse reactions are mild, rare, and generally suggestive of histamine release. 1% to 10%: Cardiovascular: Flushing> <1% (Limited to important or life-threatening): Bradycardia, bronchospasm, dyspnea, erythema, hypersensitivity reaction, hypotension, increased bronchial secretions, injection site reaction, laryngospasm, pruritus, seizure, tachycardia, urticaria, wheezing Warnings/Precautions Concerns related to adverse effects: Anaphylaxis: Severe anaphylactic reactions have been reported with atracurium use; some life-threatening and fatal. Appropriate emergency treatment (including epinephrine 1 mg/mL) should be immediately available during use. Bradycardia: May be more common with atracurium than with other neuromuscular-blocking agents since it has no clinically-significant effects on heart rate to counteract the bradycardia produced by anesthetics. Neuromuscular cross-sensitivity: Cross-sensitivity with other neuromuscular-blocking agents may occur; use extreme caution in patients with previous anaphylactic reactions. Disease-related concerns: Burn injury: Resistance may occur in burn patients ( 20% of total body surface area), usually several days after the injury, and may persist for several months after wound healing (Han 2009). Conditions which may antagonize neuromuscular blockade: Respiratory alkalosis, hypercalcemia, demyelinating lesions, peripheral neuropathies, denervation, and muscle trauma may result in antagonism of neuromuscular blockade (ACCM/SCCM/ASHP [Murray 2002]; Greenberg 2013; Miller 2010; Naguib 2002). Conditions which may potentiate neuromuscular blockade: Electrolyte abnormalities (eg, severe hypocalcemia, severe hypokalemia, hypermagnesemia), neuromuscular diseases, metabolic acidosis, metabolic alkalosis, respiratory acidosis, Eaton-Lambert syndrome and myasthenia gravis may result in potentiation of neuromuscular blockade (Greenberg 2013; Miller 2010; Naguib 2002). Concurrent drug therapy issues: Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information. Special populations: Elderly: Use with caution in the elderly, effects and duration are more variable. Immobilized patients: Resistance may occur in patients who are immobilized. Dosage form specific issues: Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol; large amounts of benzyl alcohol ( 99 mg/kg/day) have been associated with a potentially fatal toxicity ( gasping syndrome ) in neonates; the gasping syndrome consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer s labeling. Other warnings/precautions: Appropriate use: Maintenance of an adequate airway and respiratory support is critical. Resistance may develop with chronic treatment. Experienced personnel: Should be administered by adequately trained individuals familiar with its use. Histamine release: Reduce initial dosage and inject slowly (over 1 to 2 minutes) in patients in whom substantial histamine release would be potentially hazardous (eg, patients with clinically-important cardiovascular disease). Monitoring Parameters Vital signs (heart rate, blood pressure, respiratory rate); degree of muscle relaxation (via peripheral nerve stimulator and presence of spontaneous movement) In the ICU setting, prolonged paralysis and generalized myopathy, following discontinuation of agent, may be minimized by appropriately monitoring degree of blockade. Pregnancy Risk Factor C Pregnancy Considerations Adverse events were observed in animal reproduction studies. Small amounts of atracurium have been shown to cross the placenta when given to women during cesarean section. Patient Education Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?) Patient may experience flushing (HCAHPS). Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions. Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. 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