- used to produce skeletal muscle relaxation/paralysis in uncooperative neonates who are mechanically ventilated and are still in respiratory failure in spite of sedation
- 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
- 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
- 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
- 2 mg/mL single dose vial (contains no preservatives), kept in refrigerator
- Roberts, RJ: Drug Therapy in Infants, W.B. Saunders, Toronto, 1984.
- Fanaroff AA and Martin RJ (eds): Neonatal-Perinatal Medicine, Mosley, Toronto, 1992.
- Gomella TL (Ed): Neonatology - Management, Procedures, On-Call Problems, Diseases, Drugs, 1992, Appleton and Lange, Norwalk, Connecticut.
- Taeusch WH Ballard RA and Avery ME (ed): Schaffer and Avery's Diseases of the Newborn, WB Saunders Co, Toronto, Ontario; 6th Edition, 1991.
- Zenk KE, Sills JH, Koeppel RM : Neonatal Medications and Nutrition - A Comprehensive Guide. 1999. NICU INK, Santa Rosa,CA.
- Taketomo CK, Hodding JH, Kraus DM : Pediatric Dosing Handbook.2003. Lexi-Comp, Hudson,OH.