vecuronium bromide
Norcuron

Available forms
Available by prescription only
Injection: 10 mg (with or without diluent), 20 mg (without diluent)

Indications and dosages
 Adjunct to anesthesia, to facilitate intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation.  Dosages are representative and must be adjusted based on anesthetic used and individual needs and response.
Adults and children age 10 and older: Initially, 0.08 to 0.1 mg/kg I.V. bolus. Higher initial doses (up to 0.28 mg/kg) may be used for rapid onset. Maintenance doses of 0.01 to 0.015 mg/kg within 25 to 40 minutes of initial dose should be administered during prolonged surgical procedures. Maintenance doses may be given q 12 to 15 minutes in patients receiving balanced anesthetic.
 Or, after the initial dosing of 0.08 to 0.1 mg/kg, a continuous infusion of 1 mcg/kg/minute may be started 20 to 40 minutes later.

Pharmacodynamics
Skeletal muscle relaxant action: Prevents acetylcholine from binding to receptors on motor end plate, thus blocking depolarization. Exhibits minimal CV effects and doesn’t appear to alter heart rate or rhythm, systolic or diastolic blood pressure, cardiac output, systemic vascular resistance, or mean arterial pressure. Has little or no histamine-releasing effect.

Pharmacokinetics
Absorption: Administered I.V.
Distribution: After I.V. administration, distributed in extracellular fluid and rapidly reaches site of action. 60% to 90% plasma protein-bound. Volume of distribution decreased in children younger than age 1; may be decreased in elderly patients.
Metabolism: Undergoes rapid and extensive hepatic metabolism.
Excretion: Drug and metabolites appear to be primarily excreted in feces by biliary elimination; also excreted in urine.

Contraindications and precautions
Contraindicated in patients hypersensitive to vecuronium and bromides. Use cautiously in elderly patients and in patients with altered circulation caused by CV disease and edematous states, hepatic disease, severe obesity, bronchogenic carcinoma, electrolyte disturbances, or neuromuscular diseases.

Interactions
Drug-drug. Aminoglycosides, clindamycin, depolarizing neuromuscular blockers, furosemide, general anesthetics, lincomycin, nondepolarizing neuromuscular blockers, parenteral magnesium salts, polymyxin antibiotics, potassium-depleting drugs, quinidine, quinine, thiazide diuretics: Increases vecuronium-induced neuromuscular blockade. Don’t use together. When use together can’t be avoided, use together cautiously. Decrease dosage by 15%, especially with enflurane and isoflurane.
Anticholinesterases: Antagonizes effects of vecuronium. Monitor patient closely. Adjust dosage as needed.
Narcotic (opioid) analgesics: Increases central respiratory depression. Monitor respiratory status closely.

Adverse reactions
Musculoskeletal: skeletal muscle weakness.
Respiratory: prolonged, dose-related respiratory insufficiency or apnea.

Effects on lab test results
None reported.

Overdose and treatment
Signs and symptoms of overdose include prolonged duration of neuromuscular blockade, skeletal muscle weakness, decreased respiratory reserve, low tidal volume, and apnea.
 Treatment is supportive and symptomatic. Keep airway clear and maintain adequate ventilation.

Special considerations
 ALERT Have emergency respiratory support equipment immediately available. • Administration of vecuronium must be accompanied by adequate anesthesia. Drug doesn’t relieve pain or affect consciousness.
• Administer by rapid I.V. injection or I.V. infusion. Don’t give I.M.
• Diluent supplied by manufacturer contains benzyl alcohol, which isn’t intended for use in newborns.
• Don’t mix in same syringe or give through same needle as barbiturates or other alkaline solutions.
• Protect solution from light.
• Use peripheral nerve stimulator to determine and monitor degree of blockade. Give anticholinesterase (edrophonium, neostigmine, or pyridostigmine) to reverse neuromuscular blockade and atropine or glycopyrrolate to overcome muscarinic effects.
• Recovery time may double in patients with cirrhosis or cholestasis. Renal failure appears to have no effect on recovery time.
• Assess baseline serum electrolyte levels, acid-base balance, and renal and hepatic function before administration.
• Peripheral nerve stimulator may be used to identify residual paralysis during recovery and is especially useful during administration to high-risk patients.
• After procedure, monitor vital signs at least every 15 minutes until patient is stable, and then every 30 minutes for next 2 hours. Monitor airway and pattern of respirations until patient has recovered from drug effects.
• Evaluate recovery from neuromuscular blockade by checking strength of patient’s hand grip and his ability to breathe naturally, take deep breaths and cough, keep eyes open, and lift head keeping mouth closed.
Breast-feeding patients
• It isn’t known if drug appears in breast milk. Use cautiously in breast-feeding women.
Pediatric patients
• Safety and efficacy haven’t been established in infants younger than age 7 weeks.
• Infants ages 7 weeks to 1 year are more sensitive to neuromuscular blocking effects; less frequent administration may be needed.
• Higher doses may be needed in children ages 1 to 9.
Geriatric patients
• Administer cautiously to elderly patients.

Patient education
• Advise patient that drug won’t relieve pain or affect consciousness.
• Inform patient that postprocedure monitoring will involve patient demonstrating hand grip, breathing, and coughing.

Reactions may be common, uncommon, life-threatening, or COMMON AND LIFE THREATENING.
◆ Canada only
◇ Unlabeled clinical use