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Vecuronium (Monograph)

Drug class: Neuromuscular Blocking Agents
VA class: MS200
Chemical name: 1-[(2β,3α,5α,16β,17β)-3,17-bis(acetyloxy)-2-(1-piperidinyl) androstan-16-yl]-1-methylpiperidinium bromide
Molecular formula: C34H57N2O4•Br
CAS number: 50700-72-6

Medically reviewed by Drugs.com on Feb 21, 2024. Written by ASHP.

Warning

A standardized concentration for this drug has been established through Standardize 4 Safety (S4S), a national patient safety initiative to reduce medication errors, especially during transitions of care. The drug is included in a standard concentration list which may apply to an IV or oral compounded liquid formulation. For additional information, see the ASHP website [Web].

Warning

  • Should be administered only by adequately trained clinicians experienced in the use and complications of neuromuscular blocking agents.1

Introduction

Nondepolarizing neuromuscular blocking agent; aminosteroid.1 3 4 5 420

Uses for Vecuronium

Skeletal Muscle Relaxation

Production of skeletal muscle relaxation during surgery after general anesthesia has been induced.1 420

Facilitation of endotracheal intubation;1 15 16 30 39 40 41 46 54 63 68 71 77 80 113 117 124 129 131 142 however, a neuromuscular blocking agent with a rapid onset of action (e.g., succinylcholine, rocuronium) generally preferred in emergency situations when rapid intubation is required.110 111 112 141 145 421 424

Has been used to facilitate mechanical ventilation in the ICU; however, manufacturer states insufficient data available to support dosage recommendations for such use.1 186 187 188 189 190 191 192 193 341 421 Whenever neuromuscular blocking agents are used in the ICU, consider benefits versus risks of such therapy and assess patients frequently to determine need for continued paralysis.1 421 (See Intensive Care Setting under Cautions.)

Compared with other neuromuscular blocking agents, vecuronium has an intermediate onset and duration of action, and exhibits minimal cardiovascular effects.1 3 18 49 143 145 420 421 Not suitable for rapid sequence intubation, but may be used for procedures requiring profound muscle relaxation for short durations (e.g., laryngoscopy, bronchoscopy) or for maintenance of neuromuscular blockade during the postintubation period.18 145 421 424

Vecuronium Dosage and Administration

General

Dispensing and Administration Precautions

Reversal of Neuromuscular Blockade

Administration

Administer IV only;1 do not administer IM.144

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Administer initial (intubating) dose by rapid IV injection;1 administer maintenance doses by intermittent IV injection or continuous IV infusion.1

Use of a controlled-infusion device is recommended during continuous IV infusion.359

Rate of spontaneous recovery following discontinuance of a maintenance infusion usually is comparable to that following administration of a single IV injection.1

Repeated administration of maintenance doses appears to have little, if any, cumulative effect on duration of neuromuscular blockade.1 16 17 40 51 62 71 72 80 93 143

Consult specialized references for specific procedures and techniques of administration.

Do not mix in the same syringe or administer through the same needle as an alkaline solution.1

Reconstitution

Reconstitute vecuronium bromide for injection with a compatible IV solution (e.g., 5% dextrose, 5% dextrose and 0.9% sodium chloride, 0.9% sodium chloride, lactated Ringer's, bacteriostatic water for injection).1

When reconstituted with bacteriostatic water for injection, use within 5 days; when reconstituted with other compatible solutions (see Solution Compatibility under Stability), use within 24 hours and discard unused portions.1

Dilution

For continuous IV infusion, dilute the reconstituted solution to the desired concentration (usually 0.1 or 0.2 mg/mL) in a compatible IV solution (see Solution Compatibility under Stability).1 2 30 80 113

Dosage

Available as vecuronium bromide; dosage expressed in terms of the salt.1

Adjust dosage carefully according to individual requirements and response.1 2

Pediatric Patients

Skeletal Muscle Relaxation
Initial (Intubating) Dose
IV

Infants >7 weeks but <1 year of age may receive doses comparable to those used in adults, but may experience a longer period of time (about 1.5 times) to neuromuscular recovery.27 148 (See Adults under Dosage and Administration.)

Children 1–9 years of age may require slightly higher initial doses than adults.1 2 27 28 (See Adults under Dosage and Administration.)

Children >10 years of age should receive doses recommended for adults.1 2 (See Adults under Dosage and Administration.)

Maintenance Dosage
Intermittent IV Injection

Infants 7 weeks to 1 year of age may receive doses recommended for adults; however, less frequent administration may be necessary.27 148 (See Adults under Dosage and Administration and also see Pediatric Use under Cautions.)

Children 1–9 years of age may require more frequent doses than adults.1 2 28 (See Adults under Dosage and Administration.)

Children >10 years of age should receive dosages recommended for adults.1 2 (See Adults under Dosage and Administration.)

Continuous IV Infusion

Dosage recommendations not established; administration by continuous IV infusion not adequately studied in pediatric patients.1

Adults

Skeletal Muscle Relaxation
Initial (Intubating) Dose
IV

0.08–0.1 mg/kg.1 2 Following administration of this initial dose, endotracheal intubation for nonemergency surgical procedures can be performed within 2.5–3 minutes in most patients.1 61 75 (See Onset and also Duration under Pharmacokinetics.)

Reduce initial dose by about 15% (i.e., to 0.06–0.085 mg/kg) when administered >5 minutes after administration of enflurane, isoflurane, or halothane has been initiated or after steady-state anesthesia has been achieved.1 2 (See Specific Drugs under Interactions.)

If larger initial dose is required, 0.15–0.28 mg/kg has been administered in patients undergoing halothane anesthesia with minimal adverse cardiovascular effects as long as ventilation was adequately maintained.1 2

If administering following succinylcholine, reduce dose to 0.05–0.06 mg/kg with balanced anesthesia or 0.04–0.06 mg/kg with inhalation anesthesia.1 2

Maintenance Dosage
Intermittent IV Injection

0.01–0.015 mg/kg, administered as necessary, in patients receiving balanced anesthesia.1 2

0.008–0.012 mg/kg, administered as necessary, in patients receiving inhalation anesthesia.

First maintenance dose generally required 25–45 minutes after the initial dose in patients undergoing balanced or inhalation anesthesia.1 2

May administer repeat maintenance doses at relatively regular intervals (i.e., from 12–15 minutes in patients undergoing balanced anesthesia or at slightly longer intervals in those undergoing enflurane or isoflurane anesthesia).1 2

May increase dose (i.e., to >0.01–0.015 mg/kg) if longer intervals between maintenance doses are desirable.1

Continuous IV Infusion

After initial intubating dose is administered, may initiate continuous IV infusion to maintain neuromuscular blockade during prolonged procedures.1

Individualize infusion rates based on patient response to peripheral nerve stimulation.1

Manufacturer recommends initial rate of 1 mcg/kg per minute.1 Subsequently adjust infusion rate to maintain 90% neuromuscular blockade; 0.8–1.2 mcg/kg per minute usually maintains continuous neuromuscular blockade in most patients.1 39

Initiate continuous IV infusion only after early spontaneous recovery from initial IV dose is evident (approximately 20–40 minutes after administration of initial dose1 30 33 39 76 80 113 118 ).1 Required infusion rates decrease progressively and become relatively constant within 30–50 minutes.30 39 113

May need to reduce infusion rate by about 25–60% approximately 45–60 minutes following initial IV dose if steady-state anesthesia has been induced with enflurane or isoflurane.1 Reduction in infusion rate may not be necessary if steady-state anesthesia has been induced with halothane.1

Manufacturer states use of continuous IV infusion during mechanical ventilation in the ICU has not been adequately studied to date to establish dosage recommendations.1

Special Populations

Hepatic Impairment

Data currently insufficient for specific dosage recommendations.1 Some clinicians suggest usual initial dose;141 151 others suggest a reduced initial dose.141 Adjust maintenance dosing (probably with reduced doses) carefully according to patient’s response.141 151 (See Hepatic Impairment under Cautions.)

Renal Impairment

Usual initial and maintenance doses recommended for patients with renal failure who are optimally prepared with dialysis prior to surgery; monitor carefully to determine interval between doses.141 149 (See Renal Impairment under Cautions.)

Manufacturer recommends consideration of decreased initial dose if emergency surgery is necessary in patients with severe renal failure (i.e., Clcr <10 mL/minute) who are not optimally prepared with dialysis;1 2 however, most clinicians believe that usual initial dose may be given.141 Adjust maintenance doses carefully according to patient’s response.141

Geriatric Patients

Dosage necessary to maintain steady-state neuromuscular blockade30 32 33 may be decreased.

Burn Patients

Substantially increased doses may be required due to development of resistance.175 (See Burn Patients under Cautions.)

Patients with Neuromuscular Disease

Administer small test dose (e.g., 0.005–0.02 mg/kg)141 144 and monitor response.1 (See Neuromuscular Diseases under Cautions.)

Other Populations

Patients in whom substantial histamine release would be particularly hazardous (e.g., patients with clinically important cardiovascular disease) or patients with any history suggesting a greater risk of histamine release (e.g., a history of severe anaphylactoid reactions or asthma): Administer slowly over 1–2 minutes or longer; discontinue administration if any signs of histamine release occur.141 144 (See Hypersensitivity Reactions under Cautions.)

Detailed Vecuronium dosage information

Cautions for Vecuronium

Contraindications

Warnings/Precautions

Warnings

Administration Precautions

Because of the potential for severely compromised respiratory function and other complications, take special precautions during administration.1 110 111 127 128 (See Boxed Warning and also see General under Dosage and Administration.)

Neuromuscular Diseases

Possible exaggerated neuromuscular blockade in patients with neuromuscular diseases (e.g., myasthenia gravis, Eaton-Lambert syndrome).1

Administer small test dose; monitor response carefully with a peripheral nerve stimulator.1 141 144

Sensitivity Reactions

Hypersensitivity Reactions

Serious hypersensitivity reactions, including anaphylaxis, reported rarely.1 Potential for cross-sensitivity with other neuromuscular blocking agents (both depolarizing and nondepolarizing).1

Take appropriate precautions; emergency treatment for anaphylaxis should be immediately available.1

General Precautions

Burn Patients

Resistance to therapy can develop in burn patients,169 170 172 173 174 175 particularly those with burns over 25–30% or more of body surface area.175

Resistance becomes apparent ≥1 week after the burn,169 170 171 172 173 174 175 peaks ≥2 weeks after the burn,170 171 172 174 persists for several months or longer,170 172 and decreases gradually with healing.169 170 172 174

Consider possible need for substantially increased doses.175

Cardiovascular Effects

Exhibits minimal cardiovascular effects;1 3 5 6 19 143 therefore, will not counteract the bradycardia induced by many anesthesia agents1 21 59 (e.g., high-dose fentanyl)122 143 or by vagal stimulation.141

Possible delayed onset of action and delayed maximum effect in patients with impaired circulation or in those with cardiovascular disease or edema (vecuronium volume of distribution may be increased).1 2 141 Larger-than-usual initial doses are not recommended; caution advised when administering a subsequent dose before the maximum effect of the initial dose is attained.141

Intensive Care Setting

Possible prolonged paralysis and/or muscle weakness and atrophy with long-term administration of neuromuscular blocking agents in the ICU.1

Continuous monitoring of neuromuscular transmission recommended during neuromuscular blocking agent therapy in intensive care setting.1 Do not administer additional doses before there is a definite response to nerve stimulation tests.1 If no response is elicited, discontinue administration until response returns.1

Electrolyte Disturbances

Possible prolonged paralysis in patients with electrolyte disturbances (e.g., increased plasma magnesium concentrations) or acid-base imbalances.186 187 189 190

Carefully monitor the degree of neuromuscular blockade with a peripheral nerve stimulator in patients with severe electrolyte disturbances (i.e., hypermagnesemia, hypokalemia, hypocalcemia)141 or diseases that result in electrolyte disturbances (e.g., adrenocortical insufficiency).141

Malignant Hyperthermia

Malignant hyperthermia is rarely associated with use of neuromuscular blocking agents and/or potent inhalation anesthetics.1 b Insufficient data to determine whether vecuronium is capable of initiating the development of this condition.1

Be vigilant for possible development of malignant hyperthermia and prepared for its management in any patient undergoing general anesthesia.168

Carcinomatosis

Carefully monitor the degree of neuromuscular blockade with a peripheral nerve stimulator.1

Obesity

Use with caution in severely obese patients; maintenance of adequate airway and ventilation support prior to, during, and following administration of neuromuscular blocking agents may require particular care.1

Debilitated Patients

Carefully monitor the degree of neuromuscular blockade with a peripheral nerve stimulator in patients with severe debilitation.1

Specific Populations

Pregnancy

Category C.1

Lactation

Not known whether vecuronium is distributed into milk.1 141 Caution advised if used in nursing women.1 141

Pediatric Use

Safety and efficacy not established in children <7 weeks of age.1 144

Has been used safely and effectively in children >7 weeks of age who were undergoing surgery.27 28 Children 7 weeks–1 year of age may be more sensitive than adults to the neuromuscular blocking effects and generally require 50% longer to recover from neuromuscular blockade.1 2 27 148

Vecuronium bromide that has been reconstituted with bacteriostatic water for injection containing benzyl alcohol should not be used in neonates.1 163 164 165 166 167

Geriatric Use

Possible increased time to onset of neuromuscular blockade31 and decreased rate of recovery compared with younger adults.30 32 33

Hepatic Impairment

Prolonged duration of and rate of recovery from neuromuscular blockade.1 38 79 90

Use with caution; careful monitoring with a peripheral nerve stimulator recommended.1

Renal Impairment

Onset and duration of and rate of recovery from neuromuscular blockade not substantially altered by renal dysfunction;1 74 84 149 however, possible prolonged duration of blockade in patients with severe renal impairment who have not undergone dialysis prior to surgery.1 2 Careful monitoring with a peripheral nerve stimulator recommended to avoid inadvertent overdosage; consider reduced initial dose.1

Common Adverse Effects

Skeletal muscle weakness.1

Drug Interactions

Specific Drugs

Drug

Interaction

Comments

Acylaminopenicillins (e.g., piperacillin)

Prolonged neuromuscular blockade158 159

Use with caution158 159

Anesthetics, general (enflurane, halothane, isoflurane)

Increased potency and prolonged duration of neuromuscular blockade1 2 3 13 14 18 23 73 89 129 143

Reduced vecuronium dosage may be required1 2 14 23 89

Anti-infective agents (e.g., aminoglycosides, bacitracin, clindamycin, lincomycin, polymyxins, tetracyclines)

Possible prolonged duration of neuromuscular blockade1 2 3 13 18 156

Magnesium salts

Increased neuromuscular blockade;1 141 154 155 reversal may be impeded1 141 155

Use with caution; reduce vecuronium dosage as necessary1 141 154 155

Neuromuscular blocking agents

Possible increased neuromuscular blockade1

Concomitant administration not recommended1

Quinidine

Possible recurrence of paralysis1

Succinylcholine

Possible increased potency and prolonged duration of neuromuscular blockade1 2 3 21 33 62 124 131 132

Administer vecuronium in reduced dosage after effects of succinylcholine begin to dissipate1
Vecuronium drug interactions (more detail)

Vecuronium Pharmacokinetics

Absorption

Bioavailability

Poorly absorbed from the GI tract.b

Onset

Time to maximum neuromuscular blockade decreases as the dose increases.1 2 17 18 26 46 69 70 87

Following IV administration of 0.08–0.1 mg/kg, neuromuscular blockade begins within 1 minute and is maximal at 3–5 minutes.1 2

Duration

Duration of neuromuscular blockade increases as the dose increases.1 2 17 47 70 80 87

Duration of clinically sufficient neuromuscular blockade induced by initial dose of 0.08–0.1 mg/kg under balanced or halothane anesthesia is about 25–30 or 30–40 minutes, respectively.2

Spontaneous recovery to about 25% of baseline generally occurs within 25–40 minutes under balanced anesthesia and is usually 95% complete 45–65 minutes after administration.1

The time necessary for 25–75% recovery from neuromuscular blockade following doses of 0.08–0.1 mg/kg under balanced or halothane anesthesia is about 15–25 minutes;1 144 recovery time following initial doses appears to be dose dependent.17 141

Special Populations

Hepatic dysfunction (i.e., cirrhosis, cholestasis) may prolong duration of and rate of recovery from neuromuscular blockade.1 38 79 90

In patients with severe renal impairment who have not undergone dialysis prior to surgery, duration of neuromuscular blockade may be prolonged.1 2

In geriatric patients, increased time of onset31 and decreased rate of recovery from neuromuscular blockade.30 32 33

In patients undergoing cardiopulmonary bypass surgery under induced hypothermia, duration of neuromuscular blockade may be prolonged.152

Distribution

Extent

Appears to rapidly distribute into extracellular space.2 100 Undergoes rapid and extensive hepatic extraction.116 Crosses the placenta minimally;94 95 96 97 not known whether distributed into milk.144

Plasma Protein Binding

Approximately 60–90%.1 2 57 99

Special Populations

In children <1 year of age, volume of distribution is increased.148 In geriatric patients, volume of distribution may be decreased.100 In patients with renal failure, volume of distribution may be slightly increased.74 84 104

Elimination

Metabolism

Metabolic fate not fully characterized in humans.1 2 3 106 116 143 In vitro, vecuronium undergoes spontaneous deacetylation to form hydroxy derivatives.9

Elimination Route

Excreted principally in feces via biliary elimination;1 38 79 90 143 also excreted in urine.1 2 106 116

Half-life

Biphasic;1 3 18 26 38 84 94 95 98 104 terminal elimination half-life averages 65–75 minutes.1

Special Populations

In patients with cirrhosis, half-life averages 84 minutes.38

In patients with renal failure, half-life not substantially altered;84 104 potential for high plasma concentrations of 3-desacetyl vecuronium (neuromuscular blocking activity is ≥50% of that of vecuronium).186 187 189 190 84 104

During late pregnancy, half-life decreases to about 35–40 minutes.1 2 94 95

Stability

Storage

Parenteral

Powder for Injection

20–25°C; protect from light.1 2

Following reconstitution with bacteriostatic water for injection, store at room temperature or under refrigeration; use within 5 days.1

Following reconstitution with sterile water for injection or other compatible solution (see Solution Compatibility under Stability), store under refrigeration and use within 24 hours.1

Compatibility

Parenteral

Unstable in the presence of bases.10 11

Solution CompatibilityHID

Compatible

Dextrose 5% in sodium chloride 0.9%

Dextrose 5% in water

Ringer's injection, lactated

Sodium chloride 0.9%
Drug Compatibility
Admixture CompatibilityHID

Compatible

Ciprofloxacin
Y-Site CompatibilityHID

Compatible

Alprostadil

Aminophylline

Amiodarone HCl

Cefazolin sodium

Cefuroxime sodium

Clarithromycin

Co-trimoxazole

Dexmedetomidine HCl

Diltiazem HCl

Dobutamine HCl

Dopamine HCl

Epinephrine HCl

Esmolol HCl

Fenoldopam mesylate

Fentanyl citrate

Fluconazole

Gentamicin sulfate

Heparin sodium

Hetastarch in lactated electrolyte injection (Hextend)

Hydrocortisone sodium succinate

Hydromorphone HCl

Isoproterenol HCl

Labetalol HCl

Linezolid

Lorazepam

Midazolam HCl

Milrinone lactate

Morphine sulfate

Nicardipine HCl

Nitroglycerin

Norepinephrine bitartrate

Palonosetron HCl

Propofol

Ranitidine HCl

Sodium nitroprusside

Vancomycin HCl

Incompatible

Amphotericin B cholesteryl sulfate complex

Diazepam

Etomidate

Furosemide

Micafungin sodium

Actions

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Vecuronium Bromide

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injection, for IV use only

10 mg*

Vecuronium Bromide for Injection

20 mg*

Vecuronium Bromide for Injection

AHFS DI Essentials™. © Copyright 2024, Selected Revisions March 2, 2022. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

References

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11. Baraka A, Noueihed R, Sinno H et al. Succinylcholine-vecuronium (Org NC 45) sequence for cesarean section. Anesth Analg. 1983; 62:909-13. http://www.ncbi.nlm.nih.gov/pubmed/6137170?dopt=AbstractPlus

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25. Robertson EN, Fragen RJ, Booij LHDJ et al. Some effects of diisopropyl phenol (ICI 35 868) on the pharmacodynamics of atracurium and vecuronium in anaesthetized man. Br J Anaesth. 1983; 55:723-8. http://www.ncbi.nlm.nih.gov/pubmed/6136286?dopt=AbstractPlus

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27. Fisher DM, Miller RD. Neuromuscular effects of vecuronium (Org NC 45) in infants and children during N2O, halothane anesthesia. Anesthesiology. 1983; 58:519-23. http://www.ncbi.nlm.nih.gov/pubmed/6134483?dopt=AbstractPlus

28. Goudsouzian NG, Martyn JJA, Liu LMP et al. Safety and efficacy of vecuronium in adolescents and children. Anesth Analg. 1983; 62:1083-8. http://www.ncbi.nlm.nih.gov/pubmed/6139963?dopt=AbstractPlus

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36. Funk DI, Crul JF, vd Pol FM. Effects of changes in acid-base balance on neuromuscular blockade produced by Org-NC 45. Acta Anaesthesiol Scand. 1980; 24:119-24. http://www.ncbi.nlm.nih.gov/pubmed/6104411?dopt=AbstractPlus

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