Introduction

Nondepolarizing neuromuscular blocking agent; aminosteroid.

Uses for Pancuronium

Skeletal Muscle Relaxation

Production of skeletal muscle relaxation during surgery after general anesthesia has been induced.

Facilitation of endotracheal intubation; however, a neuromuscular blocking agent with a rapid onset of action (e.g., succinylcholine, rocuronium) generally preferred in emergency situations when rapid intubation is required.

Also used to facilitate mechanical ventilation in the ICU; however, manufacturer states insufficient data available to support dosage recommendations for such use. Whenever neuromuscular blocking agents are used in the ICU, consider benefits versus risks of such therapy and assess patients frequently to determine need for continued paralysis. (See Intensive Care Setting under Cautions.)

Compared with other neuromuscular blocking agents, pancuronium has a slow onset and long duration of action; therefore, not appropriate for emergency intubation but may be used for other indications (e.g., mechanical ventilation in the ICU) in which rapid onset and short duration of action are not as important.

Because of prominent vagolytic effects, generally should not be used in patients with preexisting tachycardia or in patients who cannot tolerate an increase in heart rate (e.g., those with cardiovascular disease).

Pancuronium Dosage and Administration

General

Dispensing and Administration Precautions

• Facilities and personnel necessary for intubation, administration of oxygen, and respiratory support should be immediately available. (See Boxed Warning.)

• Take special precautions (e.g., segregate storage, limit access, affix warning labels to storage containers and final administration containers) to ensure that the drug is not administered without adequate respiratory support. Institute for Safe Medication Practices (ISMP) recommends the following wording on auxiliary labels: “Warning: Paralyzing agent—causes respiratory arrest—patient must be ventilated.”

• Assess neuromuscular blockade and recovery with a peripheral nerve stimulator to accurately monitor the degree of muscle relaxation, determine need for additional doses, and minimize possibility of overdosage. (See Administration Precautions under Cautions.)

• To avoid patient distress, administer in conjunction with adequate analgesia and sedation, and only after unconsciousness has been induced.

• A reversal agent should be readily available in the event of a failed intubation or to accelerate neuromuscular recovery after surgery. (See Reversal of Neuromuscular Blockade under Dosage and Administration.)

Reversal of Neuromuscular Blockade

• To reverse neuromuscular blockade, administer a cholinesterase inhibitor (e.g., neostigmine, pyridostigmine, edrophonium) in conjunction with an anticholinergic agent such as atropine or glycopyrrolate to block adverse muscarinic effects of the cholinesterase inhibitor.

• To minimize risk of residual neuromuscular blockade, attempt reversal only after some degree of spontaneous recovery has occurred; monitor patients closely until adequate recovery of normal neuromuscular function is assured (i.e., ability to maintain satisfactory ventilation and a patent airway).

Administration

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Administer IV only. Usually administered by direct IV injection, but also has been given as a continuous IV infusion.

Use of a controlled-infusion device recommended during continuous IV infusion.

Consult specialized references for specific procedures and techniques of administration.

Dilution

For continuous IV infusion, may dilute with 5% dextrose, 5% dextrose and 0.9% sodium chloride, 0.9% sodium chloride, or lactated Ringer's injection. Infusion solutions are stable for 48 hours.

Dosage

Available as pancuronium bromide; dosage expressed in terms of the salt.

Adjust dosage carefully according to individual requirements and response.

Pediatric Patients

Skeletal Muscle Relaxation

Initial Dose

Children >1 month of age: 0.04–0.1 mg/kg as adjunct to balanced anesthesia. For endotracheal intubation, dose of 0.06–0.1 mg/kg recommended; conditions satisfactory for intubation generally occur within 2–3 minutes following this dose. (See Onset and also Duration under Pharmacokinetics.)

If administering following succinylcholine and/or maintenance doses of inhalation anesthetics (e.g., enflurane, isoflurane), select initial dose at lower end of recommended range. Administer pancuronium after effects of succinylcholine subside.

Neonates ≤1 month of age: Manufacturer recommends administering a test dose of 0.02 mg/kg to determine responsiveness. (See Intensive Care Setting under Cautions.)

Maintenance Dosage

May administer additional incremental doses starting at 0.01 mg/kg to maintain skeletal muscle relaxation during prolonged surgery.

Manufacturer states that continuous IV infusions or intermittent IV injections to support mechanical ventilation in the ICU not adequately studied to establish dosage recommendations.

Adults

Skeletal Muscle Relaxation

Initial Dose

0.04–0.1 mg/kg as adjunct to balanced anesthesia. For endotracheal intubation, dose of 0.06–0.1 mg/kg recommended; conditions satisfactory for intubation generally occur within 2–3 minutes following this dose. (See Onset and also Duration under Pharmacokinetics.)

If administering following succinylcholine and/or maintenance doses of inhalation anesthetics (e.g., enflurane, isoflurane), select initial dose at lower end of recommended range. Administer pancuronium after effects of succinylcholine subside.

Maintenance Dosage

May administer additional incremental doses starting at 0.01 mg/kg to maintain skeletal muscle relaxation during prolonged surgery.

Manufacturer states that continuous IV infusions or intermittent IV injections to support mechanical ventilation in the ICU not adequately studied to establish dosage recommendations.

Special Populations

Patients with Hepatic or Biliary Disease

Increased initial dose may be required to achieve effective neuromuscular blockade; once blockade is established, duration of blockade may be prolonged. (See Biliary Disease and also see Hepatic Impairment under Cautions.)

Burn Patients

Substantially increased doses may be required due to development of resistance. (See Burn Patients under Cautions.)

Patients with Altered Circulation Time

Patients with slower circulations (e.g., those with cardiovascular disease, edema, or advanced age) may have delayed onset; however, do not increase dosage.

Patients with Neuromuscular Diseases

Small test dose is recommended to monitor response. (See Neuromuscular Diseases under Cautions.)

Contraindications

• Known hypersensitivity to pancuronium.

Warnings/Precautions

Warnings

Administration Precautions

Because of the potential for severely compromised respiratory function and other complications, take special precautions during administration. (See Boxed Warning and also see General under Dosage and Administration.)

Sensitivity Reactions

Hypersensitivity Reactions

Serious hypersensitivity reactions, including anaphylaxis, reported rarely. Potential for cross-sensitivity with other neuromuscular blocking agents (both depolarizing and nondepolarizing).

Take appropriate precautions; emergency treatment for anaphylaxis should be immediately available.

General Precautions

Neuromuscular Diseases

Possible profound neuromuscular blockade in patients with neuromuscular diseases (e.g., myasthenia gravis, Eaton-Lambert syndrome).

Monitor degree of neuromuscular blockade with a peripheral nerve stimulator. Particular care may be required to maintain adequate airway and ventilation support prior to, during, and following administration of pancuronium.

Burn Patients

Resistance to therapy with neuromuscular blocking agents can develop in burn patients, particularly those with burns over 25–30% or more of body surface area.

Resistance generally becomes apparent ≥1 week after the burn, peaks ≥2 weeks after the burn, persists for several months or longer, and decreases gradually with healing.

Consider possible need for substantially increased doses.

Cardiovascular Effects

Possible increased heart rate, arterial pressure, and cardiac output.

Use not recommended in patients with preexisting tachycardia or in patients in whom minor elevation in heart rate is undesirable.

Possible delayed onset of action in patients with impaired circulation (e.g., cardiovascular disease, edema); however, larger than usual doses are not recommended.

Intensive Care Setting

Prolonged paralysis and severe muscle weakness reported rarely with long-term use in neonates undergoing mechanical ventilation in the ICU. Although definitive causal relationship not established, consider risks versus benefits of such use.

Continuous monitoring of neuromuscular transmission recommended during neuromuscular blocking agent therapy in intensive care setting. Do not administer additional doses before there is a definite response to nerve stimulation tests. If no response is elicited, discontinue administration until a response returns.

Obesity

Possible airway or ventilatory problems in patients with severe obesity. Particular care may be required to maintain adequate airway and ventilation support prior to, during, and following administration of pancuronium.

Biliary Disease

Possible slower onset and prolonged duration of neuromuscular blockade. (See Elimination: Special Populations, under Pharmacokinetics and also see Patients with Hepatic or Biliary Disease under Dosage and Administration.)

Specific Populations

Pregnancy

Category C.

Lactation

Not known whether pancuronium is distributed into milk.

Pediatric Use

Clinically important methemoglobinemia reported rarely in premature neonates receiving pancuronium in combination with fentanyl and atropine for emergency anesthesia and surgery; however, direct causal relationship not established.

Large amounts of benzyl alcohol (i.e., 100–400 mg/kg daily) have been associated with toxicity in neonates; each mL of pancuronium bromide injection contains 10 mg of benzyl alcohol.

Neonates (<1 month of age) are particularly sensitive to neuromuscular blocking agents; administer test dose to determine responsiveness. (See Pediatric Patients under Dosage and Administration.) Carefully consider risks and benefits of long-term therapy in neonates. (See Intensive Care Setting under Cautions.)

Hepatic Impairment

Possible slower onset and prolonged duration of neuromuscular blockade. (See Elimination: Special Populations, under Pharmacokinetics and also see Patients with Hepatic or Biliary Disease under Dosage and Administration.)

Renal Impairment

Possible prolonged neuromuscular blockade; use with caution in patients with renal failure. (See Elimination: Special Populations, under Pharmacokinetics.)

Common Adverse Effects

Various degrees of skeletal muscle weakness.

General

Dispensing and Administration Precautions

• Facilities and personnel necessary for intubation, administration of oxygen, and respiratory support should be immediately available. (See Boxed Warning.)

• Take special precautions (e.g., segregate storage, limit access, affix warning labels to storage containers and final administration containers) to ensure that the drug is not administered without adequate respiratory support. Institute for Safe Medication Practices (ISMP) recommends the following wording on auxiliary labels: “Warning: Paralyzing agent—causes respiratory arrest—patient must be ventilated.”

• Assess neuromuscular blockade and recovery with a peripheral nerve stimulator to accurately monitor the degree of muscle relaxation, determine need for additional doses, and minimize possibility of overdosage. (See Administration Precautions under Cautions.)

• To avoid patient distress, administer in conjunction with adequate analgesia and sedation, and only after unconsciousness has been induced.

• A reversal agent should be readily available in the event of a failed intubation or to accelerate neuromuscular recovery after surgery. (See Reversal of Neuromuscular Blockade under Dosage and Administration.)

Reversal of Neuromuscular Blockade

• To reverse neuromuscular blockade, administer a cholinesterase inhibitor (e.g., neostigmine, pyridostigmine, edrophonium) in conjunction with an anticholinergic agent such as atropine or glycopyrrolate to block adverse muscarinic effects of the cholinesterase inhibitor.

• To minimize risk of residual neuromuscular blockade, attempt reversal only after some degree of spontaneous recovery has occurred; monitor patients closely until adequate recovery of normal neuromuscular function is assured (i.e., ability to maintain satisfactory ventilation and a patent airway).

Administration

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Administer IV only. Usually administered by direct IV injection, but also has been given as a continuous IV infusion.

Use of a controlled-infusion device recommended during continuous IV infusion.

Consult specialized references for specific procedures and techniques of administration.

Dilution

For continuous IV infusion, may dilute with 5% dextrose, 5% dextrose and 0.9% sodium chloride, 0.9% sodium chloride, or lactated Ringer's injection. Infusion solutions are stable for 48 hours.

Dosage

Available as pancuronium bromide; dosage expressed in terms of the salt.

Adjust dosage carefully according to individual requirements and response.

Pediatric Patients

Skeletal Muscle Relaxation

Initial Dose

Children >1 month of age: 0.04–0.1 mg/kg as adjunct to balanced anesthesia. For endotracheal intubation, dose of 0.06–0.1 mg/kg recommended; conditions satisfactory for intubation generally occur within 2–3 minutes following this dose. (See Onset and also Duration under Pharmacokinetics.)

If administering following succinylcholine and/or maintenance doses of inhalation anesthetics (e.g., enflurane, isoflurane), select initial dose at lower end of recommended range. Administer pancuronium after effects of succinylcholine subside.

Neonates ≤1 month of age: Manufacturer recommends administering a test dose of 0.02 mg/kg to determine responsiveness. (See Intensive Care Setting under Cautions.)

Maintenance Dosage

May administer additional incremental doses starting at 0.01 mg/kg to maintain skeletal muscle relaxation during prolonged surgery.

Manufacturer states that continuous IV infusions or intermittent IV injections to support mechanical ventilation in the ICU not adequately studied to establish dosage recommendations.

Adults

Skeletal Muscle Relaxation

Initial Dose

0.04–0.1 mg/kg as adjunct to balanced anesthesia. For endotracheal intubation, dose of 0.06–0.1 mg/kg recommended; conditions satisfactory for intubation generally occur within 2–3 minutes following this dose. (See Onset and also Duration under Pharmacokinetics.)

If administering following succinylcholine and/or maintenance doses of inhalation anesthetics (e.g., enflurane, isoflurane), select initial dose at lower end of recommended range. Administer pancuronium after effects of succinylcholine subside.

Maintenance Dosage

May administer additional incremental doses starting at 0.01 mg/kg to maintain skeletal muscle relaxation during prolonged surgery.

Manufacturer states that continuous IV infusions or intermittent IV injections to support mechanical ventilation in the ICU not adequately studied to establish dosage recommendations.

Special Populations

Patients with Hepatic or Biliary Disease

Increased initial dose may be required to achieve effective neuromuscular blockade; once blockade is established, duration of blockade may be prolonged. (See Biliary Disease and also see Hepatic Impairment under Cautions.)

Burn Patients

Substantially increased doses may be required due to development of resistance. (See Burn Patients under Cautions.)

Patients with Altered Circulation Time

Patients with slower circulations (e.g., those with cardiovascular disease, edema, or advanced age) may have delayed onset; however, do not increase dosage.

Patients with Neuromuscular Diseases

Small test dose is recommended to monitor response. (See Neuromuscular Diseases under Cautions.)

Specific Drugs