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Disclaimer to the On-line Edition
This Manual has been designed for use in the NICU at London Health Sciences Centre (LHSC), London, Ontario, Canada, and represents clinical practice at this institution. The information contained within the Manual may not be applicable to other centres. If users of this Manual are not familiar with a drug, it is recommended that the official monograph be consulted before it is prescribed and administered. Any user of this information is advised that the contributors, Editor and LHSC are not responsible for any errors or omissions, and / or any consequences arising from the use of the information in this Manual.

PANCURONIUM
(Pavulon)(R)

Indication

  • used to produce skeletal muscle relaxation/paralysis in uncooperative neonates who are mechanically ventilated and are still in respiratory failure in spite of sedation

Pharmacology

  • pancuronium competes with acetylcholine for receptor sites on the postjunctional membrane, thereby interrupting transmission of nerve impulses at the neuromuscular junction
  • it is a non-depolarizing agent; this means that muscular paralysis can be reversed if the concentration of acetylcholine is increased, by using an anticholinesterase inhibitor such as neostigmine, edrophonium or pyridostigmine
  • the mean onset of paralysis in 100 pediatric patients was approximately 30 seconds
  • in premature infants, especially those with acidosis, hypothermia or hypotension, consideration should be given to a lower initial dose during the first week of life
  • the dose and duration do not, in general, predict the time to recovery; 20 hours is an average time to full recovery - this, however, can be prolonged by prematurity and renal failure
  • eliminated mainly unchanged by the kidneys

Side Effects

  • tachycardia, bradycardia and changes in blood pressure (both hypotension and hypertension)
  • transient rash, residual muscle weakness, prolonged dose-related apnea
  • in respiratory failure in the neonate, in approximately 1/3 of patients PaO2 will improve, in 1/3 PaO2 will remain the same, and in 1/3 PaO2 will worsen; therefore, close attention must be given to respiratory settings and FiO2

Nursing Implications

  • once the infant is "PAVULONIZED", dramatic changes in the respiratory settings may be necessary
  • aminoglycoside antibiotics (eg. gentamicin) potentiate neuromuscular blockage, leading to increased skeletal muscle relaxation
  • opiates can cause CNS respiratory depression which can add to the respiratory depressant effects of pancuronium
  • monitor baseline electrolyte values since electrolyte imbalance can potentiate neuromuscular effects
  • respiration and heart rate should be monitored continuously
  • mechanical ventilation is a prerequisite to "PAVULONIZATION"
  • must have constant nursing observation
  • give eye care every 30-60 minutes; use methylcellulose 0.5% solution to keep eyes lubricated, apply eye pad covers
  • measure accurate intake and output; renal dysfunction may prolong duration of action
  • store pancuronium in refrigerator; do not store in plastic containers or syringes, although plastic syringes may be used for administration; use only fresh solutions
  • blood gases must be done 20-30 minutes after first dose
  • observe the infant for return of skeletal muscle activity and consult the physician regarding further drug administration

DOSE OF PANCURONIUM FOR PARALYSIS

  • 0.03 to 0.1 mg/kg, every 1 to 4h prn,
    • First dose: slow (over at least 1 minute) IV push by an MD or CNS/NP
    • Subsequent doses: slow (over at least 1 minute) IV push may be given by an RN
      • Administration at intervals of 2 hours or less suggests that an increase in dose is required
      • Paralysis that extends beyond 4 to 6 hours suggests that a decrease in dose is required
      • In either of the above instances the RN should call the MD or CNS/NP to re-evaluate the dose
  • may also be given as a continuous infusion : 20 to 40 mcg/kg/h
  • dose depends on individual needs and response and must be adjusted accordingly

Example of A Calculation (for Pancuronium)

Baby's weight = 1.73 kg

Dose = 0.1 mg/kg

Dose = (0.1 mg/kg) (1.73 kg) = 0.17 mg

Concentration in amp=2 mg/mL
 =0.17 mg/0.085 mL (Round off to 0.09 mL)

THEREFORE WITHDRAW 0.09 mL FROM THE AMP

REVERSAL OF NEUROMUSCULAR BLOCKADE

  • neuromuscular blockade can be reversed by administering a cholinesterase inhibitor such as neostigmine

    DOSE - FOR REVERSAL OF NEUROMUSCULAR BLOCKADE

    • give atropine prior to neostigmine, to prevent vagal reaction (bradycardia, bronchospasm, increased salivation)
    • atropine 0.02 mg/kg slow IV push by Physician only
    • neostigmine 0.06 mg/kg slow IV push by Physician only

Supplied

  • 2 mg/mL single dose vial (contains no preservatives), kept in refrigerator

References

  1. Roberts, RJ: Drug Therapy in Infants, W.B. Saunders, Toronto, 1984.
  2. Fanaroff AA and Martin RJ (eds): Neonatal-Perinatal Medicine, Mosley, Toronto, 1992.
  3. Gomella TL (Ed): Neonatology - Management, Procedures, On-Call Problems, Diseases, Drugs, 1992, Appleton and Lange, Norwalk, Connecticut.
  4. Taeusch WH Ballard RA and Avery ME (ed): Schaffer and Avery's Diseases of the Newborn, WB Saunders Co, Toronto, Ontario; 6th Edition, 1991.
  5. Zenk KE, Sills JH, Koeppel RM : Neonatal Medications and Nutrition - A Comprehensive Guide. 1999. NICU INK, Santa Rosa,CA.
  6. Taketomo CK, Hodding JH, Kraus DM : Pediatric Dosing Handbook.2003. Lexi-Comp, Hudson,OH.



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