pancuronium


pancuronium

(pan-cure-oh-nee-yum) pancuronium,

Pavulon

(trade name)

Classification

Therapeutic: neuromuscular blocking agents nondepolarizing
Pregnancy Category: C

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: Rapidly distributes into extracellular fluid; small amounts cross the placenta.Metabolism and Excretion: Excreted mostly unchanged by the kidneys; small amounts are eliminated in bile.Half-life: 2 hr.

Time/action profile (neuromuscular blockade)

ROUTEONSETPEAKDURATION
IV30–45 sec3–4.5 min40–60 min

Contraindications/Precautions

Contraindicated in: Hypersensitivity;Hypersensitivity to bromides; Pediatric: Products containing benzyl alcohol should be avoided in neonates.Use Cautiously in: Underlying cardiovascular disease (↑ risk of arrhythmias);Dehydration or electrolyte abnormalities (should be corrected);Situations in which histamine release would be problematic;Fractures or muscle spasm;Renal impairment (↓ elimination);Hyperthermia (↑ duration/intensity of paralysis);Hepatic impairment (altered response);Shock;Extensive burns (may be more resistant to effects);Low plasma pseudocholinesterase levels (may be seen in association with anemia, dehydration, cholinesterase inhibitors/insecticides, severe liver disease, pregnancy, or hereditary predisposition);Obese patients; Obstetric / Lactation: Safety not established; may be used during caesarian section; Pediatric: Contains benzyl alcohol which can cause potentially fatal gasping syndrome in neonates; Geriatric: Age-related ↓ in renal function may result in prolonged effects.Exercise Extreme Caution in: Patients with neuromuscular diseases such as myasthenia gravis (small test dose may be used to assess response).

Adverse Reactions/Side Effects

Respiratory

  • bronchospasm

Cardiovascular

  • hypertension
  • tachycardia

Gastrointestinal

  • excessive salivation

Dermatologic

  • rash

Miscellaneous

  • allergic reactions including anaphylaxis (life-threatening)

Interactions

Drug-Drug interaction

Intensity and duration of paralysis may be prolonged by pretreatment with succinylcholine, generalanesthesia (inhalation), aminoglycosides, vancomycin, tetracyclines, polymyxin B, colistin, cyclosporine, calcium channel blockers, clindamycin, lidocaine, and other localanesthetics, lithium, quinidine, procainamide, beta blockers, potassium-losingdiuretics, or magnesium.Inhalationanesthetics including enflurane, isoflurane, halothane, desflurane, sevoflurane may enhance effects.Higher infusion rates may be required and duration of action may be shortened in patients receiving long-term carbamazepine, steroids (chronic), azathioprine or phenytoin.

Route/Dosage

Intravenous (Adults and Children >1 mo) Initial intubating dose—0.06–0.1 mg/kg initially; additional doses of 0.01 mg/kg may be given q 25–60 min to maintain paralysis. Continuous infusion—1–2 mcg/kg/min.

Availability (generic available)

Injection: 1 mg/mL

Nursing implications

Nursing assessment

  • Assess respiratory status continuously throughout therapy with neuromuscular blocking agents. These medications should be used only to facilitate intubation or in patients already intubated.
  • Neuromuscular response should be monitored with a peripheral nerve stimulator intraoperatively. 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.
  • 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.
    • 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 neuromuscular blocking agents 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: Unintended administration of a neuromuscular blocking agent instead of administration of the intended medication or administration of a neuromuscular blocking agent in the absence of ventilatory support has resulted in serious harm or death. Confusing similarities in packaging and insufficiently controlled access to these medications are often implicated in these medication errors. Store these products in a separate, locked container.
  • Dose is titrated to patient response.
    • Neuromuscular blocking agents have 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.
    • Store pancuronium in refrigerator. To prevent absorption by plastic, pancuronium should not be stored in plastic syringes. May be administered in plastic syringes.
    • Most neuromuscular blocking agents are incompatible with barbiturates and sodium bicarbonate. Do not admix.
  • Intravenous Administration
  • pH: 3.8–4.2.
  • Diluent: May be administered undiluted.Concentration: 1 mg/mL (10-mL vial); 2 mg/mL (2-mL or 5-mL vial).
  • Rate: Administer over 1–2 min.
  • Intermittent Infusion: Diluent: Add 100 mg of pancuroniuum to 250 mL of D5W, 0.9% NaCl, D5/0.9% NaCl, or LR.Concentration: 0.4 mg/mL.
  • Rate: Based on patient's weight (see Route/Dosage section).
  • Y-Site Compatibility: acyclovir, alemtuzumab, alfentanil, amifostine, amikacin, aminocaproic acid, aminophylline, amphotericin B liposome, ampicillin, ampicillin/sulbactam, anidulafungin, argatroban, azithromycin, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, busulfan, butorphanol, calcium chloride, calcium gluconate, carboplatin, carmustine, cefazolin, cefepime, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, chlorpromazine, ciprofloxacin, cisplatin, clindamycin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, dexrazoxane, diltiazem, diphenhydramine, dobutamine, docetaxel, dolasetron, dopamine, doxorubicin, doxorubicin liposomal, doxycycline, droperidol, enalaprilat, ephedrine, epinephrine, epirubicin, eptifibatide, ertapenem, erythromycin, esmolol, etomidate, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, fluconazole, fludarabine, fluorouracil, foscarnet, ganciclovir, gemcitabine, gentamicin, glycopyrrolate, granisetron, haloperidol, heparin, hydralazine, hydrocortisone sodium succinate, hydromorphone, idarubicin, ifosfamide, imipenem-cilastatin, insulin, irinotecan, isoproterenol, ketamine, ketorolac, labetalol, leucovorin calcium, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, melphalan, meperidine, meropenem, methohexital, methotrexate, methyldopate, methylprednisolone, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, mitoxantrone, morphine, moxifloxacin, mycophenolate, nafcillin, nalbuphine, naloxone, nesiritide, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxaliplatin, paclitaxel, palonosetron, pamidronate, pemetrexed, pentamidine, pentazocine, pentobarbital, phenobarbital, phenylephrine, piperacillin/tazobactam, potassium acetate, potassium chloride, potassium phosphates, procainamide, prochlorperazine, promethazine, propranolol, quinupristin/dalfopristin, ranitidine, remifentanil, sodium acetate, sodium bicarbonate, sodium phosphates, streptozocin, sufentanil, tacrolimus, teniposide, theophylline, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, trimethoprim/sulfamethoxazole, vancomycin, verapamil, vinblastine, vincristine, vinorelbine, voriconazole, zidovudine, zolendronic acid
  • Y-Site Incompatibility: allopurinol, amphotericin B colloidal, amphotericin B lipid comples, caspofungin, dantrolene, diazepam, furosemide, pantoprazole, phenytoin, thiopental

Patient/Family Teaching

  • Explain all procedures to patient receiving neuromuscular blocker therapy without general anesthesia, because consciousness is not affected by neuromuscular blocking agents 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.

pancuronium

Anesthesiology A long-acting nondepolarizing muscle relaxing anesthetic Mechanism Competitive inhibition of acetylcholine at motor end plate Pros Metabolized by plasma cholinesterase or nonenzymatic pathways, thus better in multiorgan failure Cons Evokes histamine release, causing hypotension, tachycardia. See Muscle relaxant. Nondepolarizing agent. Cf Depolarizing agent.