Download atracurium - DavisPlus

Name /bks_53161_deglins_md_disk/atracurium
02/20/2014 01:38PM
1
High Alert
atracurium (a-tra-kyoor-ee-um)
Tracrium
Classification
Therapeutic: neuromuscular blocking agents-nondepolarizing
Pregnancy Category C
Plate # 0-Composite
pg 1 # 1
(may be seen in association with anemia, dehydration, cholinesterase inhibitors/insecticides, severe liver disease, pregnancy, or hereditary predisposition); Obese patients; OB, Lactation: Safety not established (use only if benefit outweighs potential
risk to fetus); Pedi: Children ⬍1 mo (safety and effectiveness not established).
Exercise Extreme Caution in: Neuromuscular diseases such as myasthenia
gravis (small test dose may be used to assess response).
Adverse Reactions/Side Effects
Resp: bronchospasm. CV: hypotension, tachycardia. Derm: flushing, rash. Misc:
allergic reactions including ANAPHYLAXIS.
Indications
Induction of skeletal muscle paralysis and facilitation of intubation after induction of
anesthesia in surgical procedures. Facilitation of compliance during mechanical ventilation.
Action
Prevents neuromuscular transmission by blocking the effect of acetylcholine at the
myoneural junction. Has no analgesic or anxiolytic properties. Therapeutic Effects: Skeletal muscle paralysis.
Pharmacokinetics
Absorption: Following IV administration, absorption is essentially complete.
Distribution: Distributes into extracellular space; crosses the placenta.
Metabolism and Excretion: Metabolized in plasma; ⬍5% excreted unchanged
in urine.
Half-life: Infants: 20 min; Children: 17 min; Adults: 16 min;.
TIME/ACTION PROFILE (neuromuscular blockade)
ROUTE
ONSET
PEAK
DURATION
IV
1–4 min
3–5 min
20–35 min
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Pedi: Products containing benzyl alcohol
should be avoided in neonates.
Use Cautiously in: Dehydration or electrolyte abnormalities (should be corrected); Situations in which histamine release would be problematic; Fractures or
muscle spasm; Hyperthermia (qduration/intensity of paralysis); Shock; Extensive
burns (may be more resistant to effects); Low plasma pseudocholinesterase levels
⫽ Canadian drug name.
⫽ Genetic Implication.
Interactions
Drug-Drug: Intensity and duration of paralysis may be prolonged by pretreatment
with succinylcholine, general anesthesia (inhalation), aminoglycosides, vancomycin, tetracyclines, polymyxin B, colistin, clindamycin, lidocaine, and
other local anesthetics, lithium, quinidine, procainamide, beta-adrenergic
blocking agents, potassium-losing diuretics, or magnesium. Higher infusion
rates may be required and duration of action may be shortened in patients receiving
long-term carbamazepine or phenytoin.
Route/Dosage
IV (Adults and Children ⬎2 yr): 0.4– 0.5 mg/kg initially (0.25– 0.35 mg/kg if administered after steady-state anesthesia with enflurane or isoflurane or 0.3– 0.4 mg/
kg following succinylcholine); may then repeat with 0.08– 0.1 mg/kg 20– 45 min after initial dose as needed, or by continuous infusion at 5– 9 mcg/kg/min.
IV (Neonates , Infants, and Children 1 mo– 2 yr): 0.3– 0.4 mg/kg initially followed by maintenance doses of 0.3– 0.4 mg/kg as needed.
NURSING IMPLICATIONS
Assessment
● Assess respiratory status continuously throughout therapy with atracurium. Use
only to facilitate intubation or in patients already intubated.
● Monitor neuromuscular response with a peripheral nerve stimulator intraopera-
tively. Paralysis is initially selective and usually occurs sequentially in the following
muscles: levator muscles of eyelids, muscles of mastication, limb muscles, abdominal muscles, muscles of the glottis, intercostal muscles, and the diaphragm.
Recovery of muscle function usually occurs in reverse order.
● Monitor ECG, heart rate, and BP throughout administration.
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
PDF Page #1
Name /bks_53161_deglins_md_disk/atracurium
02/20/2014 01:39PM
2
● Observe the patient for residual muscle weakness and respiratory distress during
●
●
●
●
the recovery period.
Monitor infusion site frequently. If signs of tissue irritation or extravasation occur,
discontinue and restart in another vein.
Toxicity and Overdose: If overdose occurs, use peripheral nerve stimulator to
determine the degree of neuromuscular blockade. Maintain airway patency and
ventilation until recovery of normal respirations occurs.
Administration of anticholinesterase agents (neostigmine, pyridostigmine) may
be used to antagonize the action of atracurium once the patient has demonstrated
some spontaneous recovery from neuromuscular block. Atropine is usually administered prior to or concurrently with anticholinesterase agents to counteract
the muscarinic effects.
Administration of fluids and vasopressors may be necessary to treat severe hypotension or shock.
Potential Nursing Diagnoses
Ineffective breathing pattern (Indications)
Impaired verbal communication (Side Effects)
Fear (Side Effects)
Implementation
● High Alert: Unplanned administration of a neuromuscular blocking agent in-
stead of administration of the intended medication or administration of a neuromuscular blocking agent in the absence of ventilatory support has resulted in serious harm and death. Confusing similarities in packaging and insufficiently
controlled access to these medications are often implicated in these medication
errors.
● Dose is titrated to patient response.
● Atracurium has no effect on consciousness or pain threshold. Adequate anesthesia/analgesia should always be used when neuromuscular blocking agents are
used as an adjunct to surgical procedures or when painful procedures are performed. Benzodiazepines and/or analgesics should be administered concurrently
when prolonged neuromuscular blocker therapy is used for ventilator patients,
because patient is awake and able to feel all sensations.
● If eyes remain open throughout prolonged administration, protect corneas with
artificial tears.
Plate # 0-Composite
pg 2 # 2
● Store atracurium in refrigerator.
● Most neuromuscular blocking agents are incompatible with barbiturates and so-
dium bicarbonate. Do not admix.
IV Administration
● Direct IV: May be administered undiluted. Rate: Administer initial IV dose as a
bolus over 1 min.
● Intermittent Infusion: Maintenance dose is usually required 20– 45 min fol-
lowing initial dose.
● Diluent: D5W, 0.9% NaCl, or D5/0.9% NaCl. Administer every 15– 25 min or by
continuous infusion.
● Continuous Infusion: Maintenance dose is administered by infusion. Concen-
tration: 0.5 mg/mL for continuous infusion. Rate: Titrate according to patient
response.
● Syringe Compatibility: alfentanil, fentanyl, midazolam, sufentanil.
● Y-Site Compatibility: acyclovir, alemtuzumab, alfentanil, amikacin, amiodarone, amphotericin B lipid complex, anidulafungin, argatroban, ascorbic acid,
atropine, azathioprine, azithromycin, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, caclium chloride, calcium gluconate, carboplatin, caspofungin, cefazolin, cefotaxime, cefoxitin, ceftriaxone, cefuroxime, chloramphenicol, chlorpromazine, cisplatin, clindamycin,
cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin,
daptomycin, dexamethasone, dexmeditomidine, dexrazoxane, digoxin, diltiazem,
diphenhydramine, dobutamine, docetaxel, dopamine, doxorubicin hydorchloride liposome, doxycycline, enalaprilat, ephedrine, epinephrine, epirubicin, epoetin, eptifibatide, ertapenem, erythromycin, esmolol, etomidate, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, fluconazole, fludarabine,
fluorouracil, folic acid, foscarnet, gemcitabine, gentamicin, glycopyrrolate, granisetron, hetastarch, hydrocortisone sodium succinate, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, irinotecan, isoproterenol, ketorolac, labetalol, leucovorin, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate,
mannitol, mechlorethamine, meperidine, metaraminol, methotrexate, methyldopate, methylprednisolone, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, minocycline, mitoxantrone, morphine, multivitamins, mycophenolate, nafcillin, nalbuphine, naloxone, nesiritide, nicardipine, nitroglycerin,
norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, papaverine, pemetrexed, penicillin G, pentam䉷 2015 F.A. Davis Company
CONTINUED
PDF Page #2
Name /bks_53161_deglins_md_disk/atracurium
02/20/2014 01:39PM
Plate # 0-Composite
pg 3 # 3
3
PDF Page #3
CONTINUED
atracurium
idine, pentazocine, phentolamine, phenylephrine, phytonadione, potassium acetate, potassium chloride, procainamide, prochlorperazine, promethazine,
propranolol, protamine, pyridoxime, quinupristin/dalfopristin, ranitidine, sodium acetate, streptokinase, succinylcholine, sufentanil, tacrolimus, teniposide,
theophylline, thiamine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tolazoline, vancomycin, vasopressin, verapamil, vincristine, vinorelbine, zolendronic acid.
● Y-Site Incompatibility: aminophylline, amphotericin B colloidal, cefoperazone, ceftazidime, dantrolene, diazepam, diazoxide, furosemide, ganciclovir, indomethacin, pantoprazole, pentobarbital, phenobarbitol, phenytoin, sodium bicarbonate, thiopental.
Patient/Family Teaching
● Explain all procedures to patient receiving atracurium therapy without general an-
esthesia, because consciousness is not affected by atracurium alone.
● Reassure patient that communication abilities will return as the medication wears
off.
Evaluation/Desired Outcomes
● Adequate suppression of the twitch response when tested with peripheral nerve
stimulation and subsequent muscle paralysis.
● Improved compliance during mechanical ventilation.
Why was this drug prescribed for your patient?
⫽ Canadian drug name.
⫽ Genetic Implication.
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.