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Atracurium – Muscle Relaxant in Anaesthesia

Atracurium is a muscle relaxant used in anaesthesia to temporarily paralyse skeletal muscles, facilitating surgical procedures and mechanical ventilation.

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Things worth knowing about "Atracurium"

Atracurium is a muscle relaxant used in anaesthesia to temporarily paralyse skeletal muscles, facilitating surgical procedures and mechanical ventilation.

What is Atracurium?

Atracurium is a non-depolarising neuromuscular blocking agent (muscle relaxant) used in clinical anaesthesia and intensive care medicine. It belongs to the benzylisoquinolinium class of compounds and produces a temporary, complete relaxation of skeletal muscles. This facilitates surgical procedures and the mechanical ventilation of patients who require respiratory support.

Indications

Atracurium is used in the following medical situations:

Facilitating endotracheal intubation (insertion of a breathing tube into the airway)
Maintaining muscle relaxation during surgical procedures under general anaesthesia
Supporting mechanical ventilation in intensive care units
Any procedure requiring complete immobilisation of skeletal muscles

Mechanism of Action

Atracurium acts as a competitive antagonist at nicotinic acetylcholine receptors at the neuromuscular junction. It blocks the transmission of nerve impulses to skeletal muscle by preventing the binding of the natural neurotransmitter acetylcholine to its receptor. As a result, the muscle is unable to contract and remains relaxed.

A distinctive feature of atracurium is its Hofmann elimination: the drug undergoes spontaneous, non-enzymatic degradation at physiological pH and body temperature, independent of liver or kidney function. This makes atracurium particularly suitable for patients with hepatic or renal impairment.

Dosage and Administration

Atracurium is administered exclusively intravenously (i.v.) and must only be used by trained medical personnel in facilities equipped for artificial ventilation.

Intubation dose: Typically 0.3–0.6 mg/kg body weight
Maintenance dose: 0.1–0.2 mg/kg body weight as required, or as a continuous infusion
Exact dosing depends on the clinical condition, age, and concurrent medications of the patient

Side Effects

Like all medications, atracurium can cause side effects. The most common include:

Histamine release: May cause skin flushing, a drop in blood pressure, and in rare cases, allergic reactions
Transient bradycardia (slow heart rate) or tachycardia
Bronchospasm in susceptible patients
Local irritation at the injection site

Severe anaphylactic reactions are rare but possible and require immediate treatment.

Metabolite: Laudanosine

The breakdown of atracurium produces the metabolite laudanosine. At high concentrations – such as those that may occur with prolonged use in intensive care settings – laudanosine can stimulate the central nervous system and theoretically trigger seizures. However, this is not clinically relevant at standard doses.

Contraindications and Interactions

Atracurium should not be used, or used only under close monitoring, in:

Patients with known hypersensitivity to atracurium or any of its components
Patients with myasthenia gravis or other neuromuscular disorders (increased sensitivity)

Important interactions exist with:

Inhalational anaesthetics (potentiate the effect of atracurium)
Certain antibiotics (e.g., aminoglycosides) and calcium channel blockers
Anticholinesterases such as neostigmine (reverse the effect of atracurium and are used for antagonisation)

Reversal of Neuromuscular Blockade

The muscle-relaxing effect of atracurium can be reversed by administering anticholinesterase agents such as neostigmine (in combination with atropine). These substances inhibit the breakdown of acetylcholine, thereby restoring neuromuscular transmission and allowing the patient to breathe spontaneously.

References

Summary of Product Characteristics for Atracurium Besilate, European Medicines Agency (EMA), current version.
Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail's Clinical Anesthesiology, 6th edition. McGraw-Hill Education, 2018.
Naguib M, Lien CA. Pharmacology of Muscle Relaxants and Their Antagonists. In: Miller RD (ed.). Miller's Anesthesia, 8th edition. Elsevier, 2015.

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