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Product Name
:
ATRACURIUM-ELSaad
Chemical Name
:
Atracurium Besylate
Therapeutic Category
:
Neuromuscular drugs
Pharmacologic Category
:
Neuromuscular Blocker Agent, Nondepolarizing
Pharmaceutical Form
:
Ampoule
Composition
:
Atracurium Besylate 25mg / 50mg
Dosing
 
Dosing: Adult
For I.V. administration only (not to be used I.M.): Dose to effect; doses must be individualized due to interpatient variability; use ideal body weight for obese patients.
Adjunct to surgical anesthesia (neuromuscular blockade):
I.V. (bolus): 0.4-0.5 mg/kg, then 0.08-0.1 mg/kg 20-45 minutes after initial dose to maintain neuromuscular block; repeat dose at 15- to 25-minute intervals
Initial dose after succinylcholine for intubation (balanced anesthesia): 0.2-0.4 mg/kg
Pretreatment/priming: I.V.: 10% of intubating dose given 3-5 minutes before initial dose
I.V. continuous infusion: Initial: 9-10 mcg/kg/minute at initial signs of recovery from bolus dose; block is usually maintained by a rate of 5-9 mcg/kg/minute under balanced anesthesia.
ICU neuromuscular blockade:
I.V.: Initial (bolus) 0.4-0.5 mg/kg, followed by I.V. continuous infusion at an initial rate of 5-10 mcg/kg/minute; block is usually maintained by rate of 11-13 mcg/kg/minute (rates for pediatric patients may be higher).
Dosing: Pediatric
Adjunct to surgical anesthesia: I.V. (not to be used I.M.): Dose to effect; doses must be individualized due to interpatient variability; use ideal body weight for obese patients
Children 1 month to 2 years: Initial: 0.3-0.4 mg/kg followed by maintenance doses as needed to maintain neuromuscular blockade
Children >2 years: Refer to adult dosing.
Dosing: Geriatric
Refer to adult dosing.
Dosing: Renal Impairment
No adjustment is necessary.
Dosing: Hepatic Impairment
No adjustment is necessary.
Use
 
Adjunct to general anesthesia to facilitate endotracheal intubation and to relax skeletal muscles during surgery; to facilitate mechanical ventilation in ICU patients; does not relieve pain or produce sedation
Adverse Reactions
 
Mild, rare, and generally suggestive of histamine release
1% to 10%: Cardiovascular: Flushing
<1%: Bronchial secretions, erythema, hives, itching, wheezing
Postmarketing and/or case reports: Allergic reaction, bradycardia, bronchospasm, dyspnea, hypotension, injection site reaction, seizure, acute quadriplegic myopathy syndrome (prolonged use), laryngospasm, myositis ossificans (prolonged use), tachycardia, urticaria
Causes of prolonged neuromuscular blockade: Excessive drug administration; cumulative drug effect, metabolism/excretion decreased (hepatic and/or renal impairment); accumulation of active metabolites; electrolyte imbalance (hypokalemia, hypocalcemia, hypermagnesemia, hypernatremia); hypothermia
Contraindications
 
Hypersensitivity to atracurium besylate or any component of the formulation
Warnings / Precautions Drug
 

Concerns related to adverse effects:
• 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 (>30% of body) for period of 5-70 days postinjury.
• Conditions which may antagonize neuromuscular blockade: Alkalosis, hypercalcemia, demyelinating lesions, peripheral neuropathies, denervation, infection, muscle trauma, and diabetes mellitus may result in antagonism of neuromuscular blockade.
• Conditions which may potentiate neuromuscular blockade: Electrolyte abnormalities, severe hyponatremia, severe hypocalcemia, severe hypokalemia, hypermagnesemia, neuromuscular diseases, acidosis, acute intermittent porphyria, Eaton-Lambert syndrome, myasthenia gravis, renal failure, and hepatic failure may result in potentiation of neuromuscular blockade.
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: Some dosage forms may contain benzyl alcohol which has been associated with “gasping syndrome” in neonates.
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 1-2 minutes) in patients in whom substantial histamine release would be potentially hazardous (eg, patients with clinically-important cardiovascular disease).
Interactions
 
AbobotulinumtoxinA: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Acetylcholinesterase Inhibitors: May diminish the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy
Aminoglycosides: May enhance the respiratory depressant effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Calcium Channel Blockers: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy
Capreomycin: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Cardiac Glycosides: Neuromuscular-Blocking Agents may enhance the arrhythmogenic effect of Cardiac Glycosides. Risk C: Monitor therapy
Colistimethate: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk D: 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. Risk D: Consider therapy modification
Inhalational Anesthetics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy
Ketorolac: May enhance the adverse/toxic effect of Neuromuscular-Blocking Agents (Nondepolarizing). Specifically, episodes of apnea have been reported in patients using this combination. Risk C: 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. Risk C: 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. Risk C: Monitor therapy
Lincosamide Antibiotics: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Lithium: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: 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. Risk C: Monitor therapy
Magnesium Salts: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
OnabotulinumtoxinA: Neuromuscular-Blocking Agents may enhance the neuromuscular-blocking effect of OnabotulinumtoxinA. Risk C: Monitor therapy
Polymyxin B: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk D: Consider therapy modification
Procainamide: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
QuiNIDine: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
QuiNINE: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk X: Avoid combination
RimabotulinumtoxinB: Neuromuscular-Blocking Agents may enhance the neuromuscular-blocking effect of RimabotulinumtoxinB. Risk C: Monitor therapy
Spironolactone: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing). Risk C: Monitor therapy
Tetracycline Derivatives: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Vancomycin: May enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy
Pregnancy
 
C
Lactation
 
Excretion in breast milk unknown/use caution
Monitoring Parameters
 
Vital signs (heart rate, blood pressure, respiratory rate); degree of muscle relaxation (via peripheral nerve stimulator and presence of spontaneous movement); renal function (serum creatinine, BUN) and liver function when in ICU
In the ICU setting, prolonged paralysis and generalized myopathy, following discontinuation of agent, may be minimized by appropriately monitoring degree of blockade.
Mechanism of Action
 
Blocks neural transmission at the myoneural junction by binding with cholinergic receptor sites
Pharmacodynamics / Kinetics
 
Onset of action (dose dependent): 2-3 minutes
Duration: Recovery begins in 20-35 minutes following initial dose of 0.4-0.5 mg/kg under balanced anesthesia; recovery to 95% of control takes 60-70 minutes
Metabolism: Undergoes ester hydrolysis and Hofmann elimination (nonbiologic process independent of renal, hepatic, or enzymatic function); metabolites have no neuromuscular blocking properties; laudanosine, a product of Hofmann elimination, is a CNS stimulant and can accumulate with prolonged use. Laudanosine is hepatically metabolized.
Half-life elimination: Biphasic: Adults: Initial (distribution): 2 minutes; Terminal: 20 minutes
Excretion: Urine (<5%)
 
   
 
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