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Non-depolarising Neuromuscular Blocking Agent (Intermediate Duration)

Atracurium Besilate

Brand names: Tracrium

Adult dose

Dose: Intubation: 0.3–0.6 mg/kg IV; maintenance: 0.1–0.2 mg/kg; ICU infusion: 270–1620 mcg/kg/hour (titrated to train-of-four monitoring)
Route: Intravenous injection or infusion
Frequency: As required under anaesthesia or continuous infusion in ICU

Clinical pearls

  • Undergoes Hofmann elimination (spontaneous chemical degradation at physiological pH and temperature) AND ester hydrolysis — not dependent on hepatic or renal function for elimination
  • Ideal choice in patients with renal or hepatic failure (unlike pancuronium/vecuronium)
  • Laudanosine (active metabolite) accumulates with prolonged infusion — theoretically proconvulsant at very high concentrations (rarely clinically significant)
  • Train-of-four (TOF) monitoring essential for ICU continuous infusions and for assessing depth of block
  • Reversal with neostigmine + glycopyrrolate; or sugammadex (off-label for atracurium — sugammadex is licensed for rocuronium/vecuronium reversal)
  • Cisatracurium (isomer of atracurium) causes less histamine release and is preferred in some ICU settings

Contraindications

  • Known allergy to atracurium
  • Myasthenia gravis (extreme sensitivity — use only under specialist guidance if at all)

Side effects

  • Histamine release (flush, bronchospasm, hypotension — particularly with rapid bolus injection; less than d-tubocurarine)
  • Anaphylaxis (rare)
  • Prolonged neuromuscular blockade (especially in renal/hepatic impairment — Hofmann elimination makes it less susceptible than many)
  • Pain on injection (if peripheral vein)

Interactions

  • Aminoglycosides, polymyxins — enhanced neuromuscular blockade
  • Volatile anaesthetics (isoflurane, sevoflurane) — potentiate blockade
  • Lithium — may enhance and prolong blockade
  • Magnesium — enhanced blockade
  • Anticholinesterases (neostigmine, sugammadex for cisatracurium) — reversal agents

Monitoring

  • Train-of-four (TOF) neuromuscular monitoring during infusion
  • Vital signs (BP, HR — histamine release)
  • Depth of sedation and analgesia if used in ICU (NMBAs must not be used without adequate sedation/analgesia)
  • Temperature (Hofmann elimination is temperature-dependent — hypothermic patients may have prolonged blockade)

Reference: BNF; AAGBI/Association of Anaesthetists guidelines on neuromuscular blockade; FICM/ICS guidelines on ICU sedation and paralysis; https://bnf.nice.org.uk/drugs/atracurium-besilate/. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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