Pancuronium Bromide

Pronunciation: (PAN-cue-ROW-nee-uhm BROE-mide)Class: Nondepolarizing neuromuscular blocker

Trade Names:Pancuronium Bromide- Injection 1 mg/mL- Injection 2 mg/mL

Pharmacology

Binds competitively to cholinergic receptors on motor end-plate to antagonize action of acetylcholine, resulting in block of neuromuscular transmission.

Pharmacokinetics

Distribution

Vd is 241 to 280 mL/kg. Plasma protein binding is 87%; strong binding to gamma globulin and moderate to albumin.

Metabolism

Hepatic to active 3-hydroxy metabolite, which is half as potent a blocking agent as pancuronium. Other less potent metabolites include 17-hydroxy metabolite and 3,17-dihydroxy metabolite.

Elimination

Urine (40% as unchanged), bile (11% as metabolites). The t _{1/ 2} is 89 to 161 min. Plasma Cl is approximately 1.1 to 1.9 mL/min/kg.

Special Populations

Renal Function Impairment

Elimination t _½ doubles, plasma Cl reduces 60%, and Vd may be elevated and variable.

Hepatic Function Impairment

In patients with cirrhosis, the Vd increases approximately 50%, plasma Cl decreases 22%, and elimination t _½ doubles.

Biliary obstruction

Plasma Cl decreases 50%, Vd increases approximately 50%, and elimination t _½ doubles.

Indications and Usage

Adjunct to general anesthesia for induction of skeletal muscle relaxation; facilitation of management of patients undergoing mechanical ventilation; facilitation of tracheal intubation.

Contraindications

Standard considerations.

Dosage and Administration

Individualize dose to each case.

Endotracheal IntubationAdults and children older than 1 mo of age

IV bolus 0.06 to 0.1 mg/kg. Skeletal muscle relaxation usually occurs in 2 to 3 min.

Newborns younger than 1 mo of age

IV For test dose, use 0.02 mg/kg.

Surgical ProceduresAdults and children older than 1 mo of age

IV 0.04 to 0.1 mg/kg initially. For maintenance therapy, use incremental doses q 25 to 60 min beginning with 0.01 mg/kg.

Newborns younger than 1 mo of age

IV For test dose, use 0.02 mg/kg.

General Advice

• For IV administration only. Not for intradermal, subcutaneous, IM, or intra-arterial administration.
• May be diluted with sodium chloride 0.9% injection, dextrose 5% injection, dextrose 5% and sodium chloride injection, or lactated Ringer's injection.
• Do not administer if solution is cloudy, discolored, or contains particulate matter.
• Ensure that resuscitative and tracheal intubation equipment, oxygen, and an antagonist (eg, neostigmine) are available at all times.
• Ensure that peripheral nerve stimulator is used to monitor neuromuscular function during administration in order to monitor effectiveness of dosing, need for additional doses, and confirm recovery from neuromuscular blockade.
• Ensure that patient has adequate anesthesia or sedation before administering pancuronium because drug has no known effect on consciousness, pain threshold, or cerebration.

Storage/Stability

Store undiluted product in refrigerator (36° to 46°F) to maintain potency for 24 mo, or at controlled room temperature (65° to 72°F) to maintain potency for 6 mo. Diluted solution is stable for 48 h at controlled room temperature.

Drug Interactions

Aminoglycosides, bacitracin, clindamycin, colymycin, inhalational anesthetics, ketamine, lincomycin, magnesium salts, polymyxin B, quinidine, quinine, succinylcholine, tetracyclines, vancomycin

May augment action of pancuronium.

Azathioprine, mercaptopurine

May cause reversal of neuromuscular blocking effects of pancuronium.

Carbamazepine, hydantoins

May decrease duration and effect of pancuronium.

Halothane/tricyclic antidepressants

Patients receiving chronic TCA therapy who are anesthetized with halothane should use pancuronium with caution; severe ventricular arrhythmias may result.

Theophyllines

May cause possible resistance to, or reversal of, effects of pancuronium; cardiac arrhythmias may occur.

Trimethaphan

May cause prolonged apnea.

Laboratory Test Interactions

None well documented.

Adverse Reactions

Cardiovascular

Rise in arterial pressure, cardiac output, and heart rate. Decrease in central venous pressure.

Dermatologic

Transient rash.

GI

Salivation.

Respiratory

Respiratory insufficiency; apnea.

Miscellaneous

Skeletal muscle weakness to complete relaxation; hypersensitivity reactions (eg, bronchospasm, flushing, redness, hypotension, tachycardia).

Precautions

Warnings Administer via trained personnel. Have equipped facility available to monitor, assist, and control respiration.

Pregnancy

Category C ; do not use in early pregnancy.

Children

Prolonged use in newborns undergoing mechanical ventilation has been associated with severe skeletal muscle weakness and methemoglobinemia. Contains benzyl alcohol, which is related to a fatal gasping syndrome in premature infants.

Labor and Delivery

Reduce dosage in cesarean section if patient is receiving magnesium sulfate.

Renal Function

Renally excreted; may require lower doses or less frequent maintenance doses.

Altered circulation time (eg, elderly patients, patients with CV disease or edema)

Delay in onset of action.

Electrolyte imbalance

Neuromuscular blockade may be altered depending on nature of imbalance.

Hepatic or biliary tract disease

Results in slower onset and prolonged duration.

Myasthenia gravis

Small doses may have profound effects.

Obesity/Neuromuscular disease

Require special attention to airway maintenance and ventilatory support.

Pain/Anxiety

Pancuronium does not have analgesic or antianxiety effects. Paralyzed patient will still need analgesic or sedative agents if indicated.

Overdosage

Symptoms

Skeletal muscle relaxation, decreased respiratory reserve, low tidal volume, apnea, prolonged neuromuscular blockade.

Patient Information

• Advise patient, family, or caregiver that medication will be prepared and administered by a health care provider in a health care setting.
• Reassure patient, family, or caregiver that breathing will be closely monitored and supported while medication is administered and that breathing and muscle function will return to normal after medication is discontinued.

Copyright © 2009 Wolters Kluwer Health.