Atracurium Injection Uses, Dose, Side Effects | DrugsAtlas India
Authoritative Clinical Reference
Navigation
DRUG NAME: Atracurium
Therapeutic Class: Neuromuscular Blocking Agent
Subclass: Non-depolarising Benzylisoquinolinium Muscle Relaxant
Specialty: Anaesthesiology
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)
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
TAGS
atracurium; neuromuscular blocking agent; NMBA; benzylisoquinolinium; anaesthesia; intubation; muscle relaxant; ICU paralysis; renal-safe; hepatic-safe; histamine release; Schedule H
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
⚖️
Clinical Responsibility
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.
Content Feedback
Is this information helpful?
Help us improve our clinical database for the medical community.