pancuronium bromide

Available forms
Available by prescription only
Injection: 1 mg/ml, 2 mg/ml parenteral

Indications and dosages
 Adjunct to anesthesia to induce skeletal muscle relaxation, facilitate intubation and ventilation, and weaken muscle contractions in induced seizures.  Dose depends on anesthetic used, individual needs, and response. Doses are representative and must be adjusted.
Adults and children older than age 1 month: Initially, 0.04 to 0.1 mg/kg I.V.; then 0.01 mg/kg q 25 to 60 minutes if needed.

Pharmacodynamics
Skeletal muscle relaxant action: Prevents acetylcholine (ACh) from binding to receptors on the motor end-plate, thus blocking depolarization. May increase heart rate through direct blocking effect on ACh receptors of the heart; increase is dose-related. Causes little or no histamine release and no ganglionic blockade.

Pharmacokinetics
Absorption: Administered I.V.
Distribution: 87% bound to plasma proteins.
Metabolism: No information available; small amounts may be metabolized by liver.
Excretion: Mainly excreted unchanged in urine; some through biliary excretion.

Contraindications and precautions
Contraindicated in patients hypersensitive to bromides, in those with tachycardia, and in those for whom even a minor increase in heart rate is undesirable.
  Use cautiously in elderly or debilitated patients and in those with respiratory depression, myasthenia gravis, myasthenic syndrome of lung, bronchogenic cancer, dehydration, thyroid disorders, collagen diseases, porphyria, electrolyte disturbances, hyperthermia, toxemic states, or impaired renal, pulmonary, or hepatic function. Also, use large doses cautiously in patients undergoing cesarean section.

Interactions
Drug-drug. Aminoglycoside antibiotics, beta blockers, clindamycin, depolarizing neuromuscular blocking drugs, furosemide, general anesthetics, lincomycin, lithium, parenteral magnesium salts, polymyxin antibiotics, potassium-depleting drugs, quinidine, quinine, thiazide diuretics, other nondepolarizing neuromuscular blocking drugs: Potentiates pancuronium effects. Monitor patient closely.
Opioid analgesics: Increases respiratory depression. Monitor vital signs, especially respiratory rate.
Succinylcholine: Enhances and prolongs neuromuscular blocking effects of pancuronium. Monitor patient closely.

Adverse reactions
CV: tachycardia, increased blood pressure.
GI: excessive salivation.
Musculoskeletal: residual muscle weakness.
Respiratory: prolonged, dose-related respiratory insufficiency or apnea.
Skin: transient rashes.
Other: allergic or idiosyncratic hypersensitivity reactions.

Effects on lab test results
None reported.

Overdose and treatment
Toxicity may cause respiratory depression, apnea, and CV collapse.
 Use a peripheral nerve stimulator to monitor response and to evaluate neuromuscular blockade. Maintain an adequate airway and manual or mechanical ventilation until patient can maintain adequate ventilation unassisted. Neostigmine, edrophonium, or pyridostigmine may be used to reverse effects.

Special considerations
• Administration requires direct medical supervision, with emergency respiratory support available.
• If using succinylcholine, allow its effects to subside before giving pancuronium.
• Store drug in refrigerator and not in plastic container or syringes. Plastic syringes may be used to administer dose.
• Don’t mix in same syringe or give through same needle with barbiturates or other alkaline solutions.
• Reduce dosage when ether or other inhalation anesthetics that enhance neuromuscular blockade are used.
• Large doses may increase frequency and severity of tachycardia.
• Drug doesn’t relieve pain or alter consciousness; assess patient’s need for analgesic or sedative.
Breast-feeding patients
• It isn’t known if drug appears in breast milk. Use cautiously in breast-feeding women.
Pediatric patients
• Dosage for neonates younger than age 1 month must be carefully individualized. For infants older than age 1 month and children, see adult dosage.
Geriatric patients
• The usual adult dose must be individualized depending on response.

Patient education
• Explain all events and procedures to patient because he can still hear.
• Reassure patient that breathing will return to normal once therapy is discontinued.

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