Non-depolarising Neuromuscular Blocking Agent (Intermediate Duration) Pregnancy: Should only be administered to a pregnant woman if the anticipated benefit to the mother outweighs any potential risk to the foetus. Suitable for maintenance of muscle relaxation during Caesarean section as it does not cross the placenta in clinically significant amounts at recommended doses.

Atracurium Besilate

Brand names: Tracrium

Atracurium besilate is a non-depolarising neuromuscular blocking agent given intravenously to provide skeletal muscle relaxation during general anaesthesia and to facilitate tracheal intubation and mechanical ventilation.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: 0.3 to 0.6 mg/kg

Route: Intravenous injection

Frequency: Single bolus (depending on required duration of full block); supplementary doses of 0.1 to 0.2 mg/kg as required to prolong full block

Usual adult dose 0.3-0.6 mg/kg by IV injection, providing relaxation for 15-35 minutes. Endotracheal intubation usually achievable within 90 seconds after 0.5-0.6 mg/kg. Successive supplementary doses do not cause accumulation of neuromuscular blocking effect. By IV infusion: after an initial bolus of 0.3-0.6 mg/kg, continuous infusion at 0.3-0.6 mg/kg/hour during long surgical procedures. ICU: after optional initial bolus 0.3-0.6 mg/kg, maintain block by continuous infusion at 11-13 microgram/kg/min (0.65-0.78 mg/kg/hour); some patients require as low as 4.5 microgram/kg/min or as high as 29.5 microgram/kg/min. Suitable for maintenance of relaxation during Caesarean section (0.3-0.6 mg/kg) as it does not cross the placenta in clinically significant amounts. Elderly: standard dose, but initial dose at lower end of range and administered slowly. Cardiovascular disease: initial dose administered slowly over 60 seconds. Regular monitoring of neuromuscular transmission is necessary.

Paediatric dose

Route: Intravenous injection

Frequency: As per adult regimen

The dosage based on body weight in children over the age of 1 month is the same as in adults (i.e. 0.3-0.6 mg/kg by IV injection). Not recommended in neonates due to insufficient data.

Dose adjustments

Renal

No dose adjustment required in renal or hepatic impairment; standard dose is administered even in the terminal stages of disease.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to atracurium, cisatracurium or to any of the excipients

Side effects

Hypotension (mild, transient) - attributed to histamine release
Skin redness/flushing - attributed to histamine release
Bronchospasm
Anaphylactic and anaphylactoid reactions (very rare), including shock, circulatory failure and cardiac arrest
Urticaria; seizures (in ICU patients); myopathy and muscle weakness (following prolonged administration)

Interactions

Enhanced neuromuscular block with inhalational anaesthetics (enflurane, isoflurane, halothane)
Enhanced block with certain antibiotics, especially aminoglycosides and polymyxins
Enhanced block with lithium, magnesium salts, procainamide and quinidine
Prior succinylcholine quickens onset and may increase depth of block (do not administer until recovered from succinylcholine-induced block)

Clinical monograph

How it works

It competitively antagonises acetylcholine at nicotinic receptors of the neuromuscular junction; it is unique in being broken down by spontaneous Hofmann elimination and ester hydrolysis independent of organ function.

Prescribing in practice

Must only be used by clinicians experienced in airway management with facilities for intubation and ventilation immediately available, as it causes complete respiratory paralysis.
It provides no sedation or analgesia, so adequate anaesthesia must be ensured to prevent awareness while paralysed.
Histamine release can cause hypotension, flushing and bronchospasm, so administer cautiously and avoid rapid bolus injection.

Monitoring

Monitor depth of neuromuscular blockade with a peripheral nerve stimulator and confirm adequate reversal of paralysis before extubation.

Counselling the patient

Team: ensure sedation/anaesthesia is maintained throughout paralysis to prevent intraoperative awareness.
Team: have reversal agents and full ventilatory support ready before administration.

Evidence & guidelines

Its organ-independent Hofmann elimination is a well-established pharmacological property making it useful in hepatic or renal impairment.

Reference: AAGBI/Association of Anaesthetists guidelines on neuromuscular blockade; FICM/ICS guidelines on ICU sedation and paralysis; Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways