Laudanosine and atracurium concentrations in a patient receiving long-term atracurium infusion.
OBJECTIVE
Atracurium is sometimes used for muscle relaxation in patients undergoing mechanical ventilation. Use of atracurium in high doses or for a long period of time has raised the possibility of the accumulation of laudanosine, a breakdown product known to cause seizure activity in animals. The objective of this report was to see if laudanosine accumulation and seizure activity had occurred in a patient who had received a long-term, relatively high-dose infusion of atracurium.


METHODS
Case report. The patient received atracurium for 38 days, at rates ranging from 0.3 to 0.96 mg/kg/hr. An electroencephalogram (EEG) was done before the discontinuation of the infusion, and plasma concentrations of atracurium and laudanosine were measured at, and after, the termination of the atracurium infusion. The laudanosine elimination half-life was calculated.


METHODS
Intensive care unit.


METHODS
A 23-yr-old woman admitted with sickle cell crisis, complicated by acute chest syndrome, acute respiratory distress syndrome, and hepatic and renal failure.


METHODS
None.


RESULTS
As expected, laudanosine concentrations were increased but were below the level reported to cause seizure activity in animals. Laudanosine elimination half-life was prolonged to 617 mins, which was consistent with previously reported values. The patient's EEG was normal, with no ictal pattern.


CONCLUSIONS
Despite long-term use of high doses of atracurium infusion and the increased elimination half-life of laudanosine, only moderate accumulation of laudanosine occurred, and the EEG was normal. Hence, it appears unlikely that toxic concentrations of laudanosine would be reached, even in a critically ill patient.
Grigore
A M
AM
Department of Anesthesiology, St. Luke's-Roosevelt Hospital Center, New York, NY 10025, USA.
Brusco
L
L
Kuroda
M
M
Koorn
R
R
D000328:Adult; D001279:Atracurium / Q000009:adverse effects / Q000493:pharmacokinetics*; D004569:Electroencephalography; D005260:Female; D005500:Follow-Up Studies; D006207:Half-Life; D006450:Hemoglobin SC Disease / Q000150:complications / Q000378:metabolism*; D006801:Humans; D007262:Infusions, Intravenous; D007546:Isoquinolines / Q000009:adverse effects / Q000493:pharmacokinetics*; D009102:Multiple Organ Failure / Q000150:complications / Q000378:metabolism*; D003473:Neuromuscular Nondepolarizing Agents / Q000009:adverse effects / Q000493:pharmacokinetics*; D012128:Respiratory Distress Syndrome / Q000150:complications / Q000378:metabolism*; D012640:Seizures / Q000139:chemically induced / Q000378:metabolism
D007546:Isoquinolines; D003473:Neuromuscular Nondepolarizing Agents; D001279:Atracurium; C001522:laudanosine