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Drug dosage identifier

Pancuronium bromide

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Dose and administration

  • 100 micrograms/kg IV push, as needed for paralysis.
  • Usual dosing interval is 1-2 hours. Adjust dose as needed based on duration of paralysis.

Indications

  • Skeletal muscle relaxation or paralysis in infants requiring mechanical ventilation.
  • Proposed desirable effects are improved oxygenation/ventilation, reduced barotrauma and reduced cerebral blood flow fluctuations.

Contraindications and precautions

  • Known hypersensitivity to bromide.
  • Non-intubated infants.
  • Infants in whom tachycardia is undesirable.
  • Caution in infants with fluid and electrolyte imbalance.
  • Caution in infants with pulmonary, hepatic, renal disease.

Clinical pharmacology

Pancuronium is a non-depolarising muscle relaxant that competitively antagonises autonomic cholinergic receptors and also causes sympathetic stimulation. Cardiovascular effects (increased heart rate and blood pressure) are non-existent or mild. Histamine release is absent or weak. The drug is partially hydroxylated by the liver, 40% is excreted unchanged in the urine.

The dose required for neuromuscular blockage (95% depression of twitch height) is extremely variable: the daily dose ranges between 100 and 1100 mcg/kg/day. The onset of action is 1-2 minutes. Duration of neuromuscular blockade varies with dose and age. Acidosis, hypothermia, neuromuscular disease, hepatic disease, renal failure, cardiovascular disease, aminoglycosides, hypermagnesaemia, hypocalcaemia, and immaturity potentiate duration of neuromuscular blockage. Alkalosis, hypercalcaemia and adrenaline antagonise duration of neuromuscular blockage. Infants appear to recover fully from the effect of pancuronium after 20 hours.

The effects of pancuronium are reversed by neostigmine (60 micrograms/kg) and atropine (20 micrograms/kg).

Possible adverse effects

  • Hypoxaemia may occur because of inadequate mechanical ventilation and deterioration in pulmonary mechanics.
  • Tachycardia and blood pressure changes (both hypotension and hypertension) occur frequently.
  • Increased salivation.
  • Oedema secondary to third-spacing of fluids.
  • Ventricular extrasystole.
  • Muscle wasting and hypotonia associated with prolonged use.

Special considerations

  • The duration of neuromuscular blockage is influenced by acid base status, electrolyte disturbances, disease states, and a variety of drugs. The duration of effect may be either shortened or lengthened.
  • The management of pancuronium overdose includes supportive mechanical ventilation and reversal with neostigmine and atropine.

Management of Pancuronium Bromide administration

Description

  • Clear, colourless solution 2 mg/ml (=2000 micrograms/ml) in 2 ml polyamps.
  • Contains sodium chloride 6 mg/2 ml. No preservative added.

Prescription

  • Pancuronium bromide is charted under frequent drugs on the prescription chart in mcg/dose.

Administration

Slow IV Injection

  • Further dilution not required.
  • Filter prior to administration through a Pall 0.2 micron filter.
  • Administer by slow IV injection over 1 minute.
  • Compatible with NS and D5W. Also compatible with heparin.
  • Do NOT mix with other drugs, IV solutions, blood, or blood products.
  • Flush line with NS before and after injection of pancuronium.

Observation and documentation

  • Administer only to intubated babies.
  • Observe for signs of adverse reactions.
  • Use comfort measures, sedatives, and analgesics as indicated (does NOT alter pain threshold).
  • Careful positioning and changes of position. Nurse baby on sheepskin.
  • Monitor oxygenation with blood gases and pulse oximetry.
  • Careful clinical observation. Pancuronium limits ability to assess the baby.
  • Provide eye protection PRN.
  • Monitor fluid balance.
  • Careful airway care to remove secretions.
  • Express bladder PRN.
  • Keep resuscitation equipment near bedside.

Storage

  • Unopened store in refrigerator 2-8°C. May be out of refrigerator for transport. Discard at end of transport if not used.
  • Discard ampoule after use.

Selected references

  1. Costarino AT, Polen RA. Neuromuscular relaxants in the neonate. Clin Perinatol 1987; 14:965.
  2. Cabal LA, Siassi B, Artal R, et al. Cardiovascular and catecholamine changes after administration of pancuronium in distressed neonates. Pediatr 1985; 75:284.
  3. Bhutani VK, Abbasi S, Sivieri EM. Continuous skeletal muscle paralysis: effects on neonatal pulmonary mechanics. Pediatr 1988; 81:419.

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Document Control

  • Date last published: 22 February 2001
  • Document type: Drug Dosage Guideline
  • Services responsible: ADHB Pharmacy, Neonatology
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years