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Non-Depolarising Neuromuscular Blocking Agent Pregnancy: Use with caution; does not cross placenta significantly at clinical doses

Atracurium

Brand names: Tracrium

Adult dose

Dose: 0.3-0.6 mg/kg IV (intubation); 0.1-0.2 mg/kg maintenance boluses or 5-10 micrograms/kg/min infusion
Route: Intravenous
Frequency: Bolus (intubation + maintenance) or continuous infusion
Max: 0.6 mg/kg intubation dose
Onset: 2-3 minutes. Duration: 20-35 minutes. Advantage over other NMBAs: Hofmann elimination and ester hydrolysis — not organ-dependent; safe in renal and hepatic failure

Paediatric dose

Dose: 0.3-0.6 mg/kg IV mg/kg
Route: IV
Frequency: Bolus; infusion for prolonged use
Max: 0.6 mg/kg
Child 1 month to 17 years: 0.3-0.5 mg/kg. Neonates: 0.3 mg/kg — Hofmann elimination maintains safety regardless of organ maturity

Dose adjustments

Renal

No dose adjustment — Hofmann elimination and plasma esterases; not renally excreted

Hepatic

No dose adjustment — not hepatically metabolised

Paediatric weight-based calculator

Child 1 month to 17 years: 0.3-0.5 mg/kg. Neonates: 0.3 mg/kg — Hofmann elimination maintains safety regardless of organ maturity

Clinical pearls

  • Drug of choice for neuromuscular blockade in patients with renal failure, hepatic failure, or both — Hofmann elimination (spontaneous non-enzymatic degradation at physiological pH and temperature) ensures predictable offset regardless of organ function
  • Laudanosine: CNS-stimulant metabolite — CNS excitation theoretically possible with prolonged high-dose ICU infusions; cisatracurium produces less laudanosine and is preferred for ICU sedation
  • Histamine release: inject slowly over 60 seconds and use lower end of dose range — pre-treatment with H1 + H2 antihistamines reduces histamine-related effects
  • Reversal: neostigmine + glycopyrronium (traditional); sugammadex does not reverse atracurium (only rocuronium/vecuronium)
  • TOF (train-of-four) monitoring mandatory during maintenance — titrate infusion to 1-2 twitches

Contraindications

  • Use without airway management facilities
  • Hypersensitivity to atracurium

Side effects

  • Histamine release (flushing, bronchospasm, hypotension — particularly at high doses or rapid injection)
  • Laudanosine accumulation (active metabolite — potential CNS excitation in high-dose or prolonged ICU use)
  • Prolonged neuromuscular blockade (if hypothermic or electrolyte disturbance)

Interactions

  • Volatile anaesthetics (potentiate neuromuscular blockade)
  • Aminoglycosides (enhance blockade)
  • Magnesium (enhances blockade)
  • Anticholinesterases (neostigmine, sugammadex — reversal agents)

Monitoring

  • Neuromuscular monitoring (TOF)
  • SpO2 and ETCO2
  • Blood pressure (histamine-related hypotension)

Reference: BNFc; BNF 90; Tracrium SPC; AAGBI; Miller's Anaesthesia. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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