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Atracurium overdose in a small infant
A J Charlton1, N J Harper, D Edwards
1Department of Anaesthesia, Manchester Royal Infirmary.
Anaesthesia
|June 1, 1989
Insights
An infant received a high dose of atracurium due to a syringe driver error. Fortunately, the infant experienced a full recovery with no adverse effects, demonstrating the drug's rapid clearance.
Area of Science:
- Anesthesiology
- Clinical Pharmacology
- Pediatric Critical Care
Background:
- Atracurium is a neuromuscular blocking agent used in anesthesia.
- Syringe driver errors can lead to unintended medication overdoses, particularly in vulnerable infant populations.
- Understanding the pharmacokinetic profile of atracurium in infants is crucial for safe clinical practice.
Abstract:
An error in setting a syringe driver caused a 2.75 kg infant to receive 37 mg atracurium over 75 minutes. Clinically full recovery of muscle power had returned spontaneously 135 minutes after the infusion was stopped. The child suffered no ill effects. Assay of blood and urine for atracurium and laudanosine confirmed rapid clearance of the drug.