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Atracurium Injection Uses, Dose, Side Effects | DrugsAtlas India

Authoritative Clinical Reference

non depolarizing neuromuscular blocking agentnt

DRUG NAME: Atracurium

Therapeutic Class:

Peripherally acting muscle relaxant

Subclass:

Non-depolarising Benzylisoquinolinium Muscle Relaxant

Schedule (India):

Schedule H

Route(s)

Intravenous (IV)

Formulations Available in India:

Atracurium besilate injection: 10 mg/mL in 2.5 mL ampoule (25 mg)
Atracurium besilate injection: 10 mg/mL in 5 mL ampoule (50 mg)
Atracurium besilate injection: 10 mg/mL in 10 mL ampoule (100 mg)

ADULT INDICATIONS

INDICATIONS + DOSING — FOR CLINICIAN USE ONLY

Primary Indications (Approved / Standard in India)

▶️ Skeletal Muscle Relaxation during General Anaesthesia

Parameter	Details
Starting dose	0.3–0.6 mg/kg IV bolus over 30–60 seconds
Titration	Based on neuromuscular monitoring (train-of-four); adjust according to surgical requirement
Usual maintenance dose	0.1–0.2 mg/kg IV bolus every 15–25 minutes OR continuous infusion 5–10 mcg/kg/min
Maximum dose	No fixed maximum; titrate to clinical response and neuromuscular monitoring
Onset	2–3 minutes
Duration of action	20–35 minutes (initial bolus)

Clinical Notes:

Higher doses (0.5–0.6 mg/kg) provide more profound block but increase histamine release risk
Avoid rapid bolus injection to minimize histamine-related hypotension
Always ensure adequate ventilatory support before administration

▶️ Facilitation of Endotracheal Intubation

Parameter	Details
Starting dose	0.5 mg/kg IV bolus
Titration	Not applicable for intubation dose
Usual maintenance dose	As per surgical relaxation dosing above
Maximum dose	Single intubating dose as stated
Onset	2–3 minutes

Clinical Notes:

Slower onset than succinylcholine; not ideal for rapid sequence intubation
Adequate sedation/anaesthesia required before administration
Premedication with opioid/sedative may facilitate intubation conditions

▶️ Facilitation of Mechanical Ventilation in ICU

Parameter	Details
Starting dose	0.3–0.5 mg/kg IV loading bolus
Titration	Adjust infusion rate based on train-of-four monitoring; target 1–2 twitches
Usual maintenance dose	5–10 mcg/kg/min continuous IV infusion
Maximum dose	Titrate to effect; no fixed ceiling
Duration	Shortest effective duration; daily interruption recommended to assess recovery

Clinical Notes:

Specialist supervision mandatory
Concurrent adequate sedation and analgesia essential (drug provides no sedation/analgesia)
Periodic drug holidays to assess spontaneous movement and prevent prolonged weakness
Monitor for critical illness myopathy with prolonged use

Secondary Indications — Adults (Off-label, if any)

Not applicable — No established off-label indications routinely used in Indian practice.

PAEDIATRIC DOSING (Specialist Only)

Primary Indications (Approved / Standard in India)

▶️ Muscle Relaxation during General Anaesthesia and Intubation

Age Group	Starting Dose	Maintenance Dose	Clinical Notes
Neonates (<1 month)	0.3–0.4 mg/kg IV bolus	0.1 mg/kg IV bolus every 20–30 min OR 5–8 mcg/kg/min infusion	Slower onset; prolonged and variable duration; specialist supervision only
Infants (1–12 months)	0.3–0.5 mg/kg IV bolus	0.1 mg/kg IV bolus every 15–25 min OR 5–10 mcg/kg/min infusion	Dose-response variable; frequent monitoring required
Children (≥1 year)	0.4–0.5 mg/kg IV bolus	0.1 mg/kg IV bolus every 15–25 min OR 5–10 mcg/kg/min infusion	Standard paediatric range; neuromuscular monitoring recommended

Safety Monitoring:

Mandatory neuromuscular monitoring (train-of-four or peripheral nerve stimulator)
Temperature monitoring (hypothermia prolongs action)
Continuous SpO₂ and capnography monitoring

Minimum Age: Use in neonates only under paediatric anaesthesiologist supervision due to unpredictable pharmacokinetics.

Secondary Indications — Paediatrics (Off-label, if any)

▶️ ICU Paralysis for Mechanical Ventilation

Indication: Facilitation of mechanical ventilation in PICU
Dose: Loading dose 0.3–0.5 mg/kg IV; maintenance 5–10 mcg/kg/min infusion
Duration: Shortest effective duration; daily interruption to assess recovery
OFF-LABEL
Specialist only — Paediatric intensivist supervision mandatory
Evidence basis: Extrapolated from adult ICU practice; Indian PICU protocols

RENAL ADJUSTMENT

Renal Function	Recommendation
All degrees of renal impairment	No dose adjustment required
Haemodialysis	No adjustment required
CRRT	No adjustment required

Rationale: Atracurium undergoes Hofmann elimination (spontaneous degradation at physiological pH and temperature) and ester hydrolysis — both organ-independent pathways. No accumulation of active drug or metabolites occurs.

HEPATIC ADJUSTMENT

Hepatic Function	Recommendation
Mild impairment	No adjustment required
Moderate impairment	No adjustment typically required; monitor for prolonged effect
Severe impairment	Use with caution; altered acid-base status or hypothermia may affect Hofmann elimination; titrate based on neuromuscular monitoring

CONTRAINDICATIONS

Known hypersensitivity to atracurium besilate or other benzylisoquinolinium compounds
History of anaphylaxis to any neuromuscular blocking agent
Inability to provide adequate mechanical ventilation support

CAUTIONS

History of asthma, atopy, or bronchospasm — increased risk of histamine-mediated bronchospasm
Cardiovascular instability — histamine release may cause hypotension and tachycardia
Electrolyte abnormalities (hypokalaemia, hypocalcaemia, hypermagnesaemia) — potentiate neuromuscular blockade
Acidosis — may slow Hofmann elimination and prolong effect
Hypothermia — significantly slows Hofmann degradation; prolonged action
Neuromuscular disorders (myasthenia gravis, Lambert-Eaton syndrome) — extreme sensitivity; reduce dose significantly
Elderly or cachectic patients — increased sensitivity
Burns patients — resistance may develop; higher doses often required
Prolonged ICU use — risk of critical illness myopathy/polyneuropathy
Ensure reversal agents (neostigmine + glycopyrrolate) are readily available

PREGNANCY

Parameter	Details
Risk category	No formal Indian category; generally considered safe for procedural use
Use in pregnancy	May be used when general anaesthesia is required (e.g., caesarean section); minimal placental transfer
Preferred alternatives	None specific when general anaesthesia is indicated
Monitoring	Monitor maternal ventilation; assess neonatal respiratory function at delivery

LACTATION

Parameter	Details
Compatibility	Compatible with breastfeeding
Drug levels in milk	Negligible; rapid degradation and poor oral bioavailability
Preferred alternatives	None required
Infant monitoring	Not necessary for short procedural use
Resumption	May resume breastfeeding once mother is fully conscious and alert

ELDERLY

Recommended starting dose: Lower end of range (0.3 mg/kg)
Titration: Slower; allow longer intervals between supplemental doses
Additional risks: Increased sensitivity, prolonged duration of action, hypotension from histamine release
Monitoring: Mandatory neuromuscular monitoring; ensure complete recovery (TOF ratio ≥0.9) before extubation

MAJOR DRUG INTERACTIONS

Interacting Drug	Effect	Management
Aminoglycosides (gentamicin, amikacin, tobramycin)	Potentiation of neuromuscular blockade; prolonged paralysis	Avoid if possible; reduce atracurium dose; monitor closely
Magnesium sulphate	Significant enhancement of blockade via presynaptic and postsynaptic mechanisms	Reduce dose substantially; especially important in pre-eclampsia/eclampsia
Succinylcholine	Prolonged or unpredictable blockade when used sequentially	Allow recovery from succinylcholine before atracurium; reduce initial dose
Clindamycin, Lincomycin	Potentiate neuromuscular blockade	Monitor closely; may require dose reduction
Polymyxins (colistin)	Potentiate blockade	Monitor; reduce dose if concurrent use unavoidable

MODERATE DRUG INTERACTIONS

Interacting Drug	Effect	Management
Phenytoin, Carbamazepine (chronic use)	Resistance to non-depolarising blockers; reduced efficacy	May require higher doses; titrate to effect
Inhalational anaesthetics (isoflurane, sevoflurane)	Potentiate neuromuscular blockade	Reduce atracurium dose by 20–30%
Lithium	May prolong neuromuscular blockade	Monitor closely
Calcium channel blockers	May enhance duration of action	Monitor neuromuscular function
Corticosteroids (chronic/prolonged use)	Increased risk of myopathy when combined with prolonged neuromuscular blockade	Limit duration; monitor for weakness
Theophylline/Aminophylline	May reduce duration of blockade	May require higher maintenance doses
Loop diuretics	Electrolyte shifts (hypokalaemia) may potentiate blockade	Correct electrolytes; monitor

COMMON ADVERSE EFFECTS

Flushing (histamine-related)
Transient hypotension
Tachycardia
Bronchospasm (especially in asthmatics)
Skin erythema or rash
Injection site reactions
Prolonged neuromuscular blockade (dose-dependent)

SERIOUS ADVERSE EFFECTS

Anaphylaxis/Anaphylactoid reactions — rare but potentially fatal; immediate discontinuation and resuscitation required
Severe bronchospasm — especially in patients with reactive airway disease
Cardiovascular collapse — from massive histamine release (usually with rapid high-dose bolus)
Prolonged paralysis — requiring extended mechanical ventilation
Respiratory arrest — if ventilatory support inadequate
Critical illness polyneuropathy/myopathy — with prolonged ICU use

MONITORING REQUIREMENTS

Timing	Parameters
Baseline	Respiratory function, cardiovascular status, electrolytes, allergy history
During use	Continuous neuromuscular monitoring (TOF/peripheral nerve stimulator); BP; SpO₂; ETCO₂; ECG
Before extubation	Ensure TOF ratio ≥0.9; clinical assessment (sustained head lift ≥5 seconds, adequate grip strength)
Long-term ICU use	Daily drug holidays to assess spontaneous movement; monitor for signs of critical illness myopathy

BRANDS AVAILABLE IN INDIA

Atra (Neon Laboratories)
Atracurium Besilate Injection IP (Samarth)
Atracurium (Troikaa)
Tracrium (generic equivalents available)

Note: No fixed-dose combinations available

PRICE RANGE (INR)

Formulation	Approximate Price
Atracurium 25 mg (2.5 mL) ampoule	₹50–₹90
Atracurium 50 mg (5 mL) ampoule	₹80–₹150

Not under NPPA/NLEM price control
Lower pricing available through government supply channels in tertiary centres

CLINICAL PEARLS

Organ-independent metabolism — atracurium is ideal in patients with renal or hepatic impairment due to Hofmann elimination; consider as first choice in such patients
Histamine release is dose and rate-dependent — inject slowly over 60 seconds; avoid bolus doses >0.5 mg/kg to minimize hypotension and bronchospasm
Not suitable for rapid sequence intubation — onset (2–3 minutes) is too slow; succinylcholine or rocuronium (high dose) preferred for RSI
Temperature and pH matter — hypothermia and acidosis significantly slow Hofmann elimination; expect prolonged action in such patients
Cisatracurium (isomer) causes less histamine release — consider in patients at high risk of bronchospasm or cardiovascular instability, though costlier
Always use neuromuscular monitoring — clinical assessment alone is inadequate; train-of-four monitoring prevents residual blockade

VERSION

RxIndia v1.0 — 03 Feb 2026

REFERENCES

CDSCO-approved prescribing information
Indian Pharmacopoeia
AIIMS Anaesthesia protocols
Goodman & Gilman’s Pharmacological Basis of Therapeutics
Harrison’s Principles of Internal Medicine
Indian Intensive Care Society Guidelines
IAP Critical Care Module — Paediatric Ventilation Support

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This platform is designed strictly for healthcare professionals. Data provided is synthesized from authoritative pharmacological sources and clinical registries. Do not use for consumer medical decisions. Always verify critical dosing and contraindications with official institutional protocols and peer-reviewed journals.

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