pancuronium (Pavulon)
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Introduction
Tradename: Pavulon. (pancuronium bromide)
Indications
- relaxation of skeletal muscles during surgery under general anesthesia
- relaxation of skeletal muscles during endotracheal intubation
- increase pulmonary compliance during mechanical ventilation
- status asthmaticus resistant to other therapy
- neuromuscular blocking agent of choice in most critically ill patients WITHOUT significant cardiac disease or hemodynamic instability
Dosage
- ALWAYS use with sedative, i.e. lorazepam (Ativan)
- should be used with analgesic if needed
- start: 0.06-0.1 mg/kg/hr (4-5 mg) maintenance: 0.02-0.03 mg/kg (1-2 mg/hr)
- 0.04 mg/kg followed by 0.02-0.1 mg/kg every 30-60 min PRN
- titrate dose to patient's needs
Injection: 1 mg/mL (10 mL), 2 mg/mL (2 mL, 5 mL).
Dosage adjustment in renal failure
Table
| creatinine clearance | dosage |
|---|---|
| 10-50 mL/min | 50% of normal dose |
| < 10 mL/min | do NOT use |
Phamacokinetics:
- rapid onset of action (4 minutes)
- onset & duration of action are dose-dependent
- 1/2life is 2 hours
- duration 45-90 min
- metabolized in liver 30-40% to several compounds, some which are active
- eliminated mainly in the urine (55-70% as unchanged drug)
- 1/2life is prolonged in patients with hepatic or renal impairment
Adverse effects
- not common (1-10%)
- rash, excessive salivation, itching, tachycardia, hypertension (secondary to vagolytic effect)
- uncommon (< 1%)
- skin flushing, erythema, edema, circulatory collapse, bronchospasm, hypersensitivity, burning sensation along the vein, profound muscle weakness, wheezing
- other
- mast cell degranulation & histamine release
- increased risk of deep vein thrombosis (DVT)
- prolonged paralysis*
- exacerbation of adverse effects with hyperkalemia or hypokalemia
* Cholinesterase inhibitors (neostigmine, pyridostigmine, edrophonium) are used with atropine to REVERSE neuromuscular blockade
Drug interactions
- aminoglycosides, tetracyclines, clindamycin, K+-depleting agents (loop diuretics, thiazides, amphotericin B, corticosteroids) in combination increase & prolong neuromuscular blockade
- corticosteroids in combination prolong muscle weakness
- quinidine
- magnesium sulfate
- verapamil
Laboratory
- specimen:
- plasma
- stable for 20 hours at 23 degrees C, pH 5.4
- unstable at room temperature, pH 7.4
- methods: fluorometry, GC
- labs with Loincs
Mechanism of action
- non-depolarizing neuromuscular blocking agent
- diminishes response to acetylcholine at the motor endplate
More general terms
References
- ↑ Goodman and Gilman's The Pharmacological Basis of Therapeutics, 8th ed. Gilman et al, eds. Permagon Press/McGraw Hill, 1990, pg 169
- ↑ Drug Information & Medication Formulary, Veterans Affairs, Central California Health Care System, 1st ed., Ravnan et al eds, 1998 - not on National VA formulary
- ↑ Kaiser Permanente Northern California Regional Drug Formulary, 1998
- ↑ Clinical Guide to Laboratory Tests, 3rd ed. Teitz ed., W.B. Saunders, 1995
- ↑ Deprecated Reference