Atracurium Besilate

Registered South African indications:

• Muscle relaxation

Contraindications

• Hypersensitivity to the active ingredient or any of its excipients

Cautions

• Pregnancy
• Breastfeeding
• Elderly
• History of increased sensitivity to histamine effects
• Myasthenia gravis
• Eaton-Lambert syndrome
• Severe electrolyte disorders
• Burns
• Hypovolaemia
• Asthma
• Known anaphylactic reactions to curares

Forms avail. in SA and covered in this monograph: inj

Endotracheal intubation

• IV: 0.5-0.6mg/kg, as a bolus injection

Endotracheal intubation can usually be accomplished within 90-120 seconds from administration

Spontaneous recovery occurs in about 35 minutes

Maintenance of muscle relaxation for surgical procedures

• IV: 0.1-0.2mg/kg; as a bolus injection
• IV: 0.3-0.6mg/kg/hr, as an infusion (5-10μg/kg/min)

Successive supplementary dosing does not give rise to accumulation

The infusion should not be commenced until early spontaneous recovery from the initial bolus dose is evident

Paed. forms avail. in SA and covered in this monograph: inj

Endotracheal intubation
Maintenance of muscle relaxation for surgical procedures

Younger than 1 month

• Not established for use

Older than 1 month

• See adult dosage

Pregnancy

• Caution
• Atracurium crosses the placenta but there have been no demonstrated adverse effects in the foetus or newborn infant. Animal studies have indicated that atracurium has no adverse effects on foetal development. As with all neuromuscular blocking agents, the use of atracurium in the first three months of pregnancy should be avoided and it should not be used during the second and third trimesters unless clearly necessary
• Atracurium is suitable for maintenance of muscle relaxation during caesarean section as it does not cross the placenta in clinically significant amounts following recommended doses. In an open study, atracurium besilate (0.3 mg/kg) was administered to 26 pregnant women during delivery by caesarean section. No harmful effects were attributable to atracurium in any of the newborn infants, although small amounts of atracurium were shown to cross the placental barrier. The possibility of respiratory depression in the newborn infant should always be considered following caesarean section during which a neuromuscular blocking agent has been administered
• Anaesthesia during the third trimester of pregnancy exposes the mother to Mendelson syndrome (acid pneumopathy due to gastric acid aspiration). If a muscle relaxant is used at induction of anaesthesia, one should be chosen with a short onset and duration of action and low placental transfer and used in the lowest dose required to induce adequate neuromuscular relaxation. In patients receiving magnesium sulphate, the reversal of neuromuscular blockade may be unsatisfactory and the atracurium dose should be lowered as indicated

Breastfeeding

• Caution
• Atracurium has a relatively high molecular weight and is highly ionized at physiologic pH, both factors that markedly reduce transfer into milk. In addition, even though milk is slightly more acidic than plasma, any atracurium transferred into milk would be rapidly degraded. Nevertheless, in view of the potential respiratory depressant effect on the neonate, especially if premature, it is recommended that if breastfeeding is started within 24 hours after administration of atracurium, the neonate is closely monitored

Renal Impairment

• No dose adjustment recommended

Hepatic Impairment

• No dose adjustment recommended

Elderly

• Caution; no dose adjustment recommended
  Initiate at lower end of dosage range; administer slowly

Porphyria Information

• Probably not porphyrinogenic (PNP)

Drugs in Sport

• Permitted - No warnings

Central Nervous System Disorders

• Inadequate block
• Prolonged block

Cardiovascular Disorders

• Tachycardia
• Bradycardia 
• Hypertension 
• Hypotension
• Flushing

Respiratory Disorders

• Wheezing
• Broncospasm
• Dyspnoea
• Laryngospasm
• Hypoxemia
• Bronchial secretions

Skin and Subcutaneous Tissue Disorders

• Injection site reactions
• Localized skin reactions
• Rash
• Itching
• Generalized erythema
• Hives
• Angioneurotic oedema
• Urticaria

Immune, Blood and Lymphatic System Disorders

• Allergic reactions 
• Anaphylactoid reactions

• Inhalation anaesthetics
• Antibiotics
• Antiepileptics
• Antiarrhythmics
• Beta-blockers
• Antirheumatic agents
• Calcium channel blockers
• Diuretics
• Ganglion blocking agents
• Dantrolene
• Parenteral magnesium sulphate
• Chlorpromazine
• Steroids
• Ketamine
• Lithium salts
• Quinine
• Suxamethonium chloride 

None routine

Atracurium besylate is a non-depolarising neuromuscular blocking agent with an intermediate duration of action and is administered intravenously to produce skeletal muscle relaxation. Non-depolarising neuromuscular blocking agents antagonise the action of the neurotransmitter acetylcholine by competitively binding with cholinergic receptor sites on the motor endplate of the myoneural junction. These effects may be inhibited or reversed by the administration of anticholinesterases such as neostigmine or pyridostigmine.

Injection (per 2.5ml) 25mg

• Tracrium (Pharmacare) originator

Injection (per 5ml) 50mg

• Tracrium (Pharmacare) originator