Atracurium-hameln
Atracurium besylate — Neuromuscular blocking agent for surgery and intensive care
Quick Facts about Atracurium-hameln
Key Takeaways about Atracurium-hameln
- Hospital-only medication: Atracurium must only be administered by or under the direct supervision of an anaesthetist with full resuscitation facilities available
- Organ-independent elimination: Unlike most neuromuscular blockers, atracurium is degraded via Hofmann elimination, making it safe for patients with liver or kidney failure
- Intermediate duration: A single bolus dose of 0.5 mg/kg provides adequate muscle relaxation for 25–35 minutes, with full recovery typically within 60 minutes
- Reversible effect: Neuromuscular blockade can be reversed with neostigmine or edrophonium combined with atropine or glycopyrrolate
- Temperature-sensitive storage: Must be refrigerated at 2–8°C and protected from light; never frozen
What Is Atracurium-hameln and What Is It Used For?
Atracurium-hameln is a neuromuscular blocking agent (muscle relaxant) that belongs to the non-depolarizing benzylisoquinolinium class of drugs. It is used during surgical and other procedures, as well as in intensive care, to produce skeletal muscle relaxation and facilitate endotracheal intubation and controlled mechanical ventilation.
Atracurium besylate works by competitively blocking acetylcholine at the nicotinic receptors of the neuromuscular junction. When administered intravenously, it prevents nerve impulses from reaching the muscles, causing temporary paralysis. This mechanism is essential during surgery, where complete muscle relaxation is needed for the surgeon to operate effectively and safely, and during intensive care when patients require long-term mechanical ventilation.
The drug was first introduced in clinical practice in the early 1980s and has since become one of the most widely used neuromuscular blocking agents worldwide. Its development was a significant advance in anaesthesiology because of its unique pharmacokinetic profile. Atracurium is degraded through two main pathways: Hofmann elimination, a spontaneous non-enzymatic chemical breakdown that occurs at physiological pH and body temperature, and ester hydrolysis by non-specific plasma esterases. Importantly, neither pathway depends on hepatic metabolism or renal excretion, which distinguishes atracurium from older agents like pancuronium and d-tubocurarine.
This organ-independent elimination gives atracurium a major clinical advantage: it can be administered at standard doses to patients with severe hepatic or renal impairment, including those with end-stage organ failure, without risk of prolonged or unpredictable neuromuscular blockade. This property makes it a particularly valuable agent in intensive care settings, where organ dysfunction is common.
Clinical indications
Atracurium-hameln is indicated in the following clinical settings:
- General anaesthesia: To facilitate endotracheal intubation and provide skeletal muscle relaxation during surgical procedures
- Intensive care: To facilitate controlled mechanical ventilation in critically ill patients who require prolonged neuromuscular blockade
- Diagnostic procedures: To provide muscle relaxation during procedures requiring patient immobility, such as certain imaging studies
Atracurium has an intermediate duration of action, typically providing adequate surgical relaxation for 25 to 35 minutes after a standard intubating dose of 0.5–0.6 mg/kg. This duration can be extended as needed with supplementary doses or a continuous intravenous infusion. The drug does not accumulate with repeated dosing, which is another advantage for prolonged procedures.
Atracurium-hameln must only be administered by or under the supervision of an experienced clinician who is familiar with the actions and use of neuromuscular blocking agents. Facilities for endotracheal intubation, artificial ventilation, oxygen therapy, and antagonism of neuromuscular blockade must be immediately available at all times.
What Should You Know Before Taking Atracurium-hameln?
Before receiving atracurium, your medical team must be aware of any allergies, neuromuscular diseases, electrolyte disturbances, history of asthma or bronchospasm, and all other medications you are taking. Atracurium should only be used in pregnancy when clearly needed and breastfeeding should be suspended for 24 hours after administration.
Because atracurium is a potent muscle relaxant that causes temporary paralysis, its use requires careful clinical assessment. The drug is always administered in controlled healthcare settings where the patient can be continuously monitored and supported with mechanical ventilation. Before administration, the anaesthetist will evaluate several factors that could influence how the body responds to the drug.
Contraindications
Atracurium-hameln must not be used if you are allergic (hypersensitive) to atracurium besylate or any of the other ingredients in this medicine (listed in the composition section below). An allergic reaction may include skin rash, difficulty breathing, or swelling of the face, lips, throat, or tongue.
Warnings and precautions
Your medical team should be informed if you have any of the following conditions, as these may require dose adjustment or closer monitoring:
- Neuromuscular diseases: Conditions such as myasthenia gravis or Eaton-Lambert syndrome can dramatically increase sensitivity to non-depolarizing neuromuscular blocking agents. Patients with these conditions may experience profound and prolonged blockade with standard doses
- Severe electrolyte disturbances: Abnormal levels of potassium, calcium, or magnesium can alter the response to atracurium. Hypokalaemia and hypocalcaemia potentiate neuromuscular blockade, while hypermagnesaemia similarly enhances the effect
- Carcinomatosis: Widespread malignancy may alter drug distribution and sensitivity
- Histamine sensitivity: Atracurium can cause dose-dependent histamine release. Patients with a history of allergy, asthma, or bronchospasm may be at increased risk of adverse effects related to histamine release, including bronchospasm, hypotension, and skin flushing
- Burns: Patients with extensive burns may develop resistance to non-depolarizing neuromuscular blocking agents, potentially requiring higher doses
- Hypovolaemia: Patients with reduced blood volume may be more susceptible to the cardiovascular effects of histamine release
- Cardiovascular disease: Patients with significant cardiovascular disease may be more sensitive to transient hypotension; in these patients, atracurium should be administered slowly or in divided doses
Use in children
Atracurium can be used in children over one month of age at the same weight-based doses as adults. However, use in neonates (infants under one month) is not recommended due to insufficient data. If neuromuscular blockade is absolutely necessary in neonates or premature infants, the dose should be significantly reduced and neuromuscular function should be closely monitored using a peripheral nerve stimulator.
Pregnancy and breastfeeding
Atracurium should only be given to pregnant women when the potential benefit justifies the potential risk to the foetus. There are limited data on the use of atracurium during pregnancy, and animal studies are insufficient to determine reproductive toxicity. Atracurium is commonly used during caesarean section under general anaesthesia, where it does not appear to cross the placenta in clinically significant amounts at recommended doses.
Mothers who have received atracurium should not breastfeed for at least 24 hours after administration. It is not known whether atracurium or its metabolites are excreted in human breast milk, and caution should therefore be exercised.
Driving and operating machinery
After receiving atracurium, you must not drive, operate machinery, or work in hazardous conditions. You should not go home unaccompanied and should not consume alcohol until you are fully recovered from the effects of anaesthesia. The effects of the drug itself are short-lived, but the overall anaesthetic procedure requires a standard recovery period.
How Does Atracurium-hameln Interact with Other Drugs?
Atracurium interacts with numerous drug classes. Volatile anaesthetics, aminoglycoside antibiotics, magnesium salts, and calcium channel blockers can potentiate (strengthen) neuromuscular blockade. Chronic anticonvulsant therapy may reduce the effect. Your anaesthesia team will adjust the dose based on concurrent medications.
Drug interactions with neuromuscular blocking agents are clinically significant because they can lead to either prolonged paralysis or inadequate muscle relaxation. The anaesthesia team carefully considers all concurrent medications before administering atracurium. The following table summarizes the most important known interactions.
| Drug / Drug Class | Effect on Blockade | Mechanism | Clinical Significance |
|---|---|---|---|
| Volatile anaesthetics (isoflurane, sevoflurane, desflurane) | Potentiation (enhanced blockade) | Central and peripheral muscle relaxant effects | High — dose reduction of atracurium often required |
| Aminoglycoside antibiotics (gentamicin, tobramycin, amikacin) | Potentiation | Pre- and post-synaptic inhibition of neuromuscular transmission | High — can cause recurarization |
| Polymyxins (colistin, polymyxin B) | Potentiation | Direct neuromuscular blocking effect | High — potentially prolonged blockade |
| Magnesium sulfate | Potentiation | Reduced acetylcholine release and reduced end-plate sensitivity | High — common in obstetric patients with pre-eclampsia |
| Calcium channel blockers (verapamil, nifedipine, diltiazem) | Potentiation | Interference with calcium-dependent neuromuscular transmission | Moderate — monitor neuromuscular function |
| Quinidine / Procainamide | Potentiation | Local anaesthetic effect at neuromuscular junction | Moderate — can cause recurarization postoperatively |
| Loop diuretics (furosemide) | Potentiation | Electrolyte depletion (hypokalaemia) | Moderate — correct electrolytes preoperatively |
| Lithium | Potentiation | Reduced acetylcholine synthesis and release | Moderate |
| Ketamine | Potentiation | Direct muscle relaxant effect | Low to moderate |
| Carbamazepine / Phenytoin (chronic use) | Resistance (reduced blockade) | Upregulation of acetylcholine receptors | Moderate — higher doses may be needed |
Incompatibilities
Atracurium besylate is inactivated at high pH and must never be mixed in the same syringe as thiopental or any other alkaline solution. If both drugs are administered through the same intravenous line, the cannula must be thoroughly flushed between injections to prevent the formation of precipitate that could trigger an anaphylactoid reaction.
Atracurium is hypotonic and must not be administered through a blood transfusion set. When infusion is required, a separate intravenous line should be used.
What Is the Correct Dosage of Atracurium-hameln?
Atracurium is given intravenously only. The standard intubating dose for adults is 0.5–0.6 mg/kg, providing adequate relaxation for 25–35 minutes. Maintenance doses of 0.1–0.2 mg/kg are given as needed, typically every 15–25 minutes. Continuous infusion can be used at 0.3–0.6 mg/kg/hour for prolonged procedures.
Atracurium-hameln must only be given by or under the supervision of an experienced anaesthetist. The dose is individualized based on the patient's weight, the type and duration of the procedure, and the response to neuromuscular monitoring. The drug is administered exclusively by intravenous injection or infusion — it must never be given intramuscularly.
Adults
Intubation dose
The recommended dose range is 0.3–0.6 mg/kg, depending on the duration of blockade required. A dose of 0.5–0.6 mg/kg generally allows endotracheal intubation within 90 seconds and provides 25–35 minutes of adequate surgical relaxation.
Maintenance doses
Supplementary doses of 0.1–0.2 mg/kg extend the blockade by approximately 15–25 minutes. The first maintenance dose is typically needed 20–45 minutes after the initial bolus. Repeated supplementary doses do not lead to accumulation of the neuromuscular blocking effect.
Continuous infusion
After an initial bolus, atracurium can be administered by continuous intravenous infusion at a rate of 0.3–0.6 mg/kg/hour (5–10 mcg/kg/min) to maintain neuromuscular blockade during prolonged surgical procedures.
Children (over 1 month)
Children older than one month of age receive the same weight-based dosage as adults. Neuromuscular monitoring should be used to guide dosing in all paediatric patients.
Neonates
Atracurium is not recommended for use in neonates (infants under one month of age) due to insufficient clinical data. If neuromuscular blockade is absolutely necessary in neonates or premature infants, the dose should be significantly reduced and neuromuscular function should be continuously monitored with a peripheral nerve stimulator.
Elderly patients
Atracurium can be used at standard doses in elderly patients. However, it is advisable to use the lower end of the dose range and to administer the drug slowly to minimize potential cardiovascular effects from histamine release.
Patients with renal or hepatic impairment
Atracurium can be used at standard doses in patients with renal or hepatic impairment, including those with end-stage organ failure. This is because atracurium is eliminated primarily through Hofmann degradation and ester hydrolysis, neither of which depends on liver or kidney function.
Intensive care patients
For ICU patients requiring prolonged mechanical ventilation, atracurium can be administered as a continuous infusion after an optional initial bolus of 0.3–0.6 mg/kg. The maintenance infusion rate is typically 11–13 mcg/kg/min (0.66–0.78 mg/kg/hour), though individual requirements vary considerably. Some patients may need as little as 4.5 mcg/kg/min or as much as 29.5 mcg/kg/min. Dosing should be guided by peripheral nerve stimulation monitoring (train-of-four). Recovery after cessation of infusion is independent of the duration of administration.
Hypothermia
Induced hypothermia to a core body temperature of 25–26°C slows the rate of Hofmann degradation. During cardiopulmonary bypass with hypothermia, the infusion rate should be reduced by approximately half.
| Patient Group | Initial Dose | Maintenance | Notes |
|---|---|---|---|
| Adults | 0.3–0.6 mg/kg IV bolus | 0.1–0.2 mg/kg every 15–25 min or 0.3–0.6 mg/kg/h infusion | Intubation within 90 seconds at 0.5–0.6 mg/kg |
| Children (>1 month) | Same as adults (weight-based) | Same as adults | Use neuromuscular monitoring |
| Neonates | Not recommended | Significantly reduced if essential | Insufficient data; use nerve stimulator |
| Elderly | Lower end of range; slow injection | Standard | Monitor cardiovascular effects |
| Renal/hepatic impairment | Standard doses | Standard | Organ-independent elimination via Hofmann |
| ICU patients | 0.3–0.6 mg/kg bolus (optional) | 11–13 mcg/kg/min infusion (range 4.5–29.5) | Guide by train-of-four monitoring |
| Burns patients | Higher doses may be required | Titrate to response | Resistance develops depending on burn extent and timing |
Reversal of neuromuscular blockade
When signs of spontaneous recovery are present, atracurium-induced neuromuscular blockade can be rapidly reversed using standard doses of anticholinesterase agents such as neostigmine or edrophonium, given together with or following atropine or glycopyrrolate. There is no evidence of recurarization following adequate reversal of atracurium blockade.
Overdose
Since atracurium is administered by healthcare professionals in a controlled clinical environment, overdose is very unlikely. In the event of an overdose, the patient would remain on mechanical ventilation until spontaneous recovery of neuromuscular function occurs or the blockade is reversed with anticholinesterase agents. Atracurium does not accumulate, and Hofmann elimination ensures that breakdown continues independently of organ function.
What Are the Side Effects of Atracurium-hameln?
The most common side effects of atracurium are transient skin flushing, urticaria, mild hypotension, tachycardia, and bronchospasm — all related to histamine release. These effects can be minimized by slow injection. Severe allergic reactions including anaphylaxis are very rare but can occur.
Like all medicines, atracurium can cause side effects, although not everybody gets them. Most side effects of atracurium are related to its ability to cause dose-dependent histamine release from mast cells. This effect is more pronounced with rapid injection or higher doses. Administering the drug slowly over 60 seconds or more, or in divided doses, can significantly reduce the incidence of histamine-related effects.
Common
- Tachycardia — increased heart rate, usually transient
- Hypotension — temporary low blood pressure due to histamine release
- Bronchospasm — wheezing or asthma-like symptoms, particularly in susceptible individuals
- Skin flushing — redness of the skin, especially along the injection site and upper body
- Urticaria — hives or itchy welts on the skin
Very Rare
- Severe allergic reactions — including anaphylaxis, circulatory collapse, and cardiac arrest in patients receiving atracurium together with one or more anaesthetic agents
- Seizures — reported in ICU patients receiving multiple medications; causality not established
- Myasthenia / myopathy — muscle weakness or dysfunction, typically associated with prolonged ICU use in combination with corticosteroids
- Laryngospasm — spasm of the vocal cords causing difficulty breathing
Histamine release and how to minimize it
The most clinically significant adverse effect of atracurium is histamine release. When atracurium is injected rapidly, especially at doses above 0.5 mg/kg, histamine is released from tissue mast cells. This can produce skin flushing (typically along the chest, neck, and face), urticaria, bronchospasm, and transient hypotension. These effects are generally mild and self-limiting, lasting only a few minutes.
The following measures help minimize histamine-related effects:
- Administer atracurium slowly over at least 60 seconds
- Consider giving the dose in divided increments over 1–2 minutes, especially in patients with cardiovascular disease or a history of asthma
- Avoid doses above 0.5 mg/kg as a rapid bolus
- Ensure adequate preoperative hydration to reduce the impact of hypotension
ICU-acquired weakness
Prolonged use of neuromuscular blocking agents in the ICU, particularly when combined with corticosteroids, has been associated with the development of ICU-acquired myopathy and prolonged weakness. This is a class effect of all neuromuscular blockers and is not specific to atracurium. Current guidelines recommend using the lowest effective dose, guiding therapy with neuromuscular monitoring, and regularly assessing the ongoing need for neuromuscular blockade.
Reporting suspected adverse reactions after the medicine has been authorised is important. It allows continued monitoring of the benefit-risk balance of the medicine. Healthcare professionals and patients are encouraged to report any suspected adverse reactions to their national pharmacovigilance authority.
How Should You Store Atracurium-hameln?
Atracurium-hameln must be stored in a refrigerator at 2–8°C and must not be frozen. Keep ampoules in the outer carton to protect from light. Use immediately after opening. Diluted infusion solutions are stable for up to 24 hours in normal saline at up to 30°C.
Proper storage of atracurium is critical because the drug undergoes Hofmann elimination at a rate that is temperature-dependent. At higher temperatures, the drug breaks down more rapidly, reducing its potency and shelf life. The following storage guidelines must be strictly followed:
- Temperature: Store in a refrigerator at 2–8°C. Do not freeze
- Light protection: Keep the ampoules in the outer carton to protect from light
- After opening: Use immediately. Any remaining solution in opened ampoules must be discarded
- Keep out of sight and reach of children
- Expiry date: Do not use after the expiry date stated on the label and carton (EXP). The expiry date refers to the last day of that month
- Visual inspection: Do not use if the solution is not clear, colourless, and free from particles, or if the packaging is damaged
Stability of diluted solutions
When diluted for infusion, atracurium besylate solutions have the following stability at concentrations of at least 0.5 mg/ml at temperatures up to 30°C:
| Infusion Solution | Stability Duration | Storage Conditions |
|---|---|---|
| Sodium chloride 0.9% | 24 hours | Up to 30°C, daylight |
| Glucose 5% | 8 hours | Up to 30°C, daylight |
| Ringer's solution | 8 hours | Up to 30°C, daylight |
| Sodium chloride 0.18% / Glucose 4% | 8 hours | Up to 30°C, daylight |
| Compound sodium lactate (Hartmann's) | 4 hours | Up to 30°C, daylight |
From a microbiological perspective, the diluted solution should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and should normally not exceed 24 hours at 2–8°C, unless dilution has been performed under controlled and validated aseptic conditions.
What Does Atracurium-hameln Contain?
Each millilitre of Atracurium-hameln contains 10 mg of atracurium besylate as the active ingredient. The excipients are benzenesulfonic acid and water for injections. It is supplied in 2.5 ml and 5 ml clear glass ampoules.
Active ingredient
The active substance is atracurium besylate (also known as atracurium besilate). Each millilitre contains 10 mg of atracurium besylate. This means:
- Each 2.5 ml ampoule contains 25 mg atracurium besylate
- Each 5.0 ml ampoule contains 50 mg atracurium besylate
Excipients
The other ingredients are:
- Benzenesulfonic acid — used as a pH adjuster to maintain the acidic environment needed for stability
- Water for injections — the solvent
Appearance and packaging
Atracurium-hameln is a clear, colourless solution for injection or infusion. It is available in the following pack sizes:
- Cartons of 5 ampoules × 2.5 ml
- Cartons of 10 ampoules × 2.5 ml
- Cartons of 5 × 10 ampoules × 2.5 ml
- Cartons of 5 ampoules × 5 ml
- Cartons of 10 ampoules × 5 ml
- Cartons of 5 × 10 ampoules × 5 ml
Not all pack sizes may be marketed in all countries.
Marketing authorisation holder and manufacturer
Marketing authorisation holder: hameln pharma gmbh, Inselstrasse 1, 31787 Hameln, Germany
Manufacturer: Siegfried Hameln GmbH, Langes Feld 13, 31789 Hameln, Germany
This medicine is also available under the brand name Atracurium Kalceks from other manufacturers.
Frequently Asked Questions about Atracurium-hameln
Medical References
All medical information is based on evidence-based international sources. Level 1A evidence where available.
- European Medicines Agency (EMA). Atracurium besylate — Summary of Product Characteristics. Available at: ema.europa.eu
- British National Formulary (BNF). Atracurium besylate. NICE Evidence Services, 2025. Available at: bnf.nice.org.uk
- World Health Organization (WHO). WHO Model List of Essential Medicines, 23rd edition, 2023. Atracurium is listed as an essential medicine for general anaesthesia.
- Stenlake JB, et al. Atracurium: conception and inception. British Journal of Anaesthesia. 1983;55 Suppl 1:3S–10S. doi:10.1093/bja/55.Supplement_1.3S
- Naguib M, Lien CA. Pharmacology of muscle relaxants and their antagonists. In: Miller RD, ed. Miller's Anesthesia. 9th ed. Elsevier; 2020:832–882.
- Appiah-Ankam J, Hunter JM. Pharmacology of neuromuscular blocking drugs. Continuing Education in Anaesthesia Critical Care & Pain. 2004;4(1):2–7. doi:10.1093/bjaceaccp/mkh002
- Murray MJ, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Critical Care Medicine. 2016;44(11):2079–2103. doi:10.1097/CCM.0000000000002027
- U.S. Food and Drug Administration (FDA). Atracurium Besylate Injection — Prescribing Information. Available at: fda.gov
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