Pancuronium (Monograph)

Drug class: Neuromuscular Blocking Agents
VA class: MS300
CAS number: 15500-66-0

Medically reviewed by Drugs.com on Oct 12, 2023. Written by ASHP.

Introduction

Nondepolarizing neuromuscular blocking agent; aminosteroid.¹⁰⁰

Uses for Pancuronium

Skeletal Muscle Relaxation

Production of skeletal muscle relaxation during surgery after general anesthesia has been induced.^{100 420}

Facilitation of endotracheal intubation;¹⁰⁰ 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.^{421 424}

Also used to facilitate mechanical ventilation in the ICU;^{341 420 421} however, manufacturer states insufficient data available to support dosage recommendations for such use.¹⁰⁰ 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.^{100 421} (See Intensive Care Setting under Cautions.)

Compared with other neuromuscular blocking agents, pancuronium has a slow onset and long duration of action; therefore, not appropriate for emergency intubation but may be used for other indications (e.g., mechanical ventilation in the ICU) in which rapid onset and short duration of action are not as important.^{100 420 421 424}

Because of prominent vagolytic effects, generally should not be used in patients with preexisting tachycardia or in patients who cannot tolerate an increase in heart rate (e.g., those with cardiovascular disease).^{341 420 421 424}

Pancuronium Dosage and Administration

General

Dispensing and Administration Precautions

• Facilities and personnel necessary for intubation, administration of oxygen, and respiratory support should be immediately available.^{100 359 424} (See Boxed Warning.)

• Take special precautions (e.g., segregate storage, limit access, affix warning labels to storage containers and final administration containers) to ensure that the drug is not administered without adequate respiratory support.⁴²⁵ Institute for Safe Medication Practices (ISMP) recommends the following wording on auxiliary labels: “Warning: Paralyzing agent—causes respiratory arrest—patient must be ventilated.”⁴²⁵

• Assess neuromuscular blockade and recovery with a peripheral nerve stimulator to accurately monitor the degree of muscle relaxation, determine need for additional doses, and minimize possibility of overdosage.^{100 421} (See Administration Precautions under Cautions.)

• To avoid patient distress, administer in conjunction with adequate analgesia and sedation, and only after unconsciousness has been induced.^{100 359 421 423}

• A reversal agent should be readily available in the event of a failed intubation or to accelerate neuromuscular recovery after surgery.^{100 359 421} (See Reversal of Neuromuscular Blockade under Dosage and Administration.)

Reversal of Neuromuscular Blockade

• To reverse neuromuscular blockade, administer a cholinesterase inhibitor (e.g., neostigmine, pyridostigmine, edrophonium) in conjunction with an anticholinergic agent such as atropine or glycopyrrolate to block adverse muscarinic effects of the cholinesterase inhibitor.¹⁰⁰

• To minimize risk of residual neuromuscular blockade, attempt reversal only after some degree of spontaneous recovery has occurred; monitor patients closely until adequate recovery of normal neuromuscular function is assured (i.e., ability to maintain satisfactory ventilation and a patent airway).^{100 355 356 357 358 421}

Administration

IV Administration

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

Administer IV only.¹⁰⁰ Usually administered by direct IV injection, but also has been given as a continuous IV infusion.^{100 341}

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

Consult specialized references for specific procedures and techniques of administration.

Dilution

For continuous IV infusion, may dilute with 5% dextrose, 5% dextrose and 0.9% sodium chloride, 0.9% sodium chloride, or lactated Ringer's injection.¹⁰⁰ Infusion solutions are stable for 48 hours.¹⁰⁰

Dosage

Available as pancuronium bromide; dosage expressed in terms of the salt.¹⁰⁰

Adjust dosage carefully according to individual requirements and response.¹⁰⁰

Pediatric Patients

Skeletal Muscle Relaxation

Initial Dose

IV

Children >1 month of age: 0.04–0.1 mg/kg as adjunct to balanced anesthesia.¹⁰⁰ For endotracheal intubation, dose of 0.06–0.1 mg/kg recommended; conditions satisfactory for intubation generally occur within 2–3 minutes following this dose.¹⁰⁰ (See Onset and also Duration under Pharmacokinetics.)

If administering following succinylcholine and/or maintenance doses of inhalation anesthetics (e.g., enflurane, isoflurane), select initial dose at lower end of recommended range.¹⁰⁰ Administer pancuronium after effects of succinylcholine subside.¹⁰⁰

Neonates ≤1 month of age: Manufacturer recommends administering a test dose of 0.02 mg/kg to determine responsiveness.¹⁰⁰ (See Intensive Care Setting under Cautions.)

Maintenance Dosage

IV

May administer additional incremental doses starting at 0.01 mg/kg to maintain skeletal muscle relaxation during prolonged surgery.¹⁰⁰

Manufacturer states that continuous IV infusions or intermittent IV injections to support mechanical ventilation in the ICU not adequately studied to establish dosage recommendations.¹⁰⁰

Adults

Skeletal Muscle Relaxation

Initial Dose

IV

0.04–0.1 mg/kg as adjunct to balanced anesthesia.¹⁰⁰ For endotracheal intubation, dose of 0.06–0.1 mg/kg recommended; conditions satisfactory for intubation generally occur within 2–3 minutes following this dose.¹⁰⁰ (See Onset and also Duration under Pharmacokinetics.)

If administering following succinylcholine and/or maintenance doses of inhalation anesthetics (e.g., enflurane, isoflurane), select initial dose at lower end of recommended range.¹⁰⁰ Administer pancuronium after effects of succinylcholine subside.¹⁰⁰

Maintenance Dosage

IV

May administer additional incremental doses starting at 0.01 mg/kg to maintain skeletal muscle relaxation during prolonged surgery.¹⁰⁰

Manufacturer states that continuous IV infusions or intermittent IV injections to support mechanical ventilation in the ICU not adequately studied to establish dosage recommendations.¹⁰⁰

Special Populations

Patients with Hepatic or Biliary Disease

Increased initial dose may be required to achieve effective neuromuscular blockade; once blockade is established, duration of blockade may be prolonged.¹⁰⁰ (See Biliary Disease and also see Hepatic Impairment under Cautions.)

Burn Patients

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

Patients with Altered Circulation Time

Patients with slower circulations (e.g., those with cardiovascular disease, edema, or advanced age) may have delayed onset; however, do not increase dosage.¹⁰⁰

Patients with Neuromuscular Diseases

Small test dose is recommended to monitor response.¹⁰⁰ (See Neuromuscular Diseases under Cautions.)

Cautions for Pancuronium

Contraindications

• Known hypersensitivity to pancuronium.¹⁰⁰

Warnings/Precautions

Warnings

Administration Precautions

Because of the potential for severely compromised respiratory function and other complications, take special precautions during administration.^{100 c} (See Boxed Warning and also see General under Dosage and Administration.)

Sensitivity Reactions

Hypersensitivity Reactions

Serious hypersensitivity reactions, including anaphylaxis, reported rarely.^{100 422} Potential for cross-sensitivity with other neuromuscular blocking agents (both depolarizing and nondepolarizing).^{100 422}

Take appropriate precautions; emergency treatment for anaphylaxis should be immediately available.¹⁰⁰

General Precautions

Neuromuscular Diseases

Possible profound neuromuscular blockade in patients with neuromuscular diseases (e.g., myasthenia gravis, Eaton-Lambert syndrome).¹⁰⁰

Monitor degree of neuromuscular blockade with a peripheral nerve stimulator.¹⁰⁰ Particular care may be required to maintain adequate airway and ventilation support prior to, during, and following administration of pancuronium.¹⁰⁰

Burn Patients

Resistance to therapy with neuromuscular blocking agents can develop in burn patients,^c particularly those with burns over 25–30% or more of body surface area.^c

Resistance generally becomes apparent ≥1 week after the burn, peaks ≥2 weeks after the burn, persists for several months or longer, and decreases gradually with healing.^c

Consider possible need for substantially increased doses.^c

Cardiovascular Effects

Possible increased heart rate, arterial pressure, and cardiac output.¹⁰⁰

Use not recommended in patients with preexisting tachycardia or in patients in whom minor elevation in heart rate is undesirable.^{341 420 421 424}

Possible delayed onset of action in patients with impaired circulation (e.g., cardiovascular disease, edema); however, larger than usual doses are not recommended.¹⁰⁰

Intensive Care Setting

Prolonged paralysis and severe muscle weakness reported rarely with long-term use in neonates undergoing mechanical ventilation in the ICU.¹⁰⁰ Although definitive causal relationship not established, consider risks versus benefits of such use.¹⁰⁰

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

Obesity

Possible airway or ventilatory problems in patients with severe obesity.¹⁰⁰ Particular care may be required to maintain adequate airway and ventilation support prior to, during, and following administration of pancuronium.¹⁰⁰

Biliary Disease

Possible slower onset and prolonged duration of neuromuscular blockade.¹⁰⁰ (See Elimination: Special Populations, under Pharmacokinetics and also see Patients with Hepatic or Biliary Disease under Dosage and Administration.)

Specific Populations

Pregnancy

Category C.¹⁰⁰

Lactation

Not known whether pancuronium is distributed into milk.¹⁰⁶

Pediatric Use

Clinically important methemoglobinemia reported rarely in premature neonates receiving pancuronium in combination with fentanyl and atropine for emergency anesthesia and surgery; however, direct causal relationship not established.¹⁰⁰

Large amounts of benzyl alcohol (i.e., 100–400 mg/kg daily) have been associated with toxicity in neonates;^{100 114 115 116 117 118} each mL of pancuronium bromide injection contains 10 mg of benzyl alcohol.¹⁰⁰

Neonates (<1 month of age) are particularly sensitive to neuromuscular blocking agents; administer test dose to determine responsiveness.¹⁰⁰ (See Pediatric Patients under Dosage and Administration.) Carefully consider risks and benefits of long-term therapy in neonates.¹⁰⁰ (See Intensive Care Setting under Cautions.)

Hepatic Impairment

Possible slower onset and prolonged duration of neuromuscular blockade.¹⁰⁰ (See Elimination: Special Populations, under Pharmacokinetics and also see Patients with Hepatic or Biliary Disease under Dosage and Administration.)

Renal Impairment

Possible prolonged neuromuscular blockade; use with caution in patients with renal failure.¹⁰⁰ (See Elimination: Special Populations, under Pharmacokinetics.)

Common Adverse Effects

Various degrees of skeletal muscle weakness.¹⁰⁰

Drug Interactions

Specific Drugs

Pancuronium Pharmacokinetics

Absorption

Bioavailability

Poorly absorbed from the GI tract.^c

Onset

Onset of paralysis is dose related.^b

Following IV administration of 0.06 mg/kg, clinically sufficient neuromuscular blockade occurs within 2–3 minutes.^b

Duration

Duration of paralysis is dose related.^b

Duration of clinically sufficient neuromuscular blockade induced by 0.06 mg/kg is about 35–45 minutes.^b

Duration of clinically sufficient neuromuscular blockade induced by 0.1 mg/kg approximately 100 minutes.¹⁰⁰

Supplemental doses may increase magnitude and duration of neuromuscular blockade.^b

Distribution

Extent

Crosses the placenta in small amounts.^b

Plasma Protein Binding

Approximately 87% (mainly γ-globulin; albumin to a lesser extent).^{100 101 102 104} May be concentration dependent.^{101 103 104}

Special Populations

Hepatic¹⁰³ or renal¹⁰⁵ impairment does not affect protein binding. Impaired hepatic or biliary function may increase volume of distribution.¹⁰⁰

Elimination

Metabolism

Undergoes limited biotransformation.^b

Elimination Route

Excreted principally in urine as unchanged drug and to a lesser extent in bile.¹⁰⁰

Half-life

Triphasic; terminal half-life is approximately 2 hours.^b

Special Populations

Impaired renal or hepatic function or biliary disease may decrease clearance and prolong half-life.¹⁰⁰

Stability

Storage

Parenteral

Injection

2–8°C.¹⁰⁰ May store for ≤6 months at room temperature.¹⁰⁰

Compatibility

Parenteral

Solution Compatibility100

Drug Compatibility

Actions

• Produces skeletal muscle relaxation by causing a decreased response to acetylcholine (ACh) at the myoneural (neuromuscular) junction of skeletal muscle.^c

• Exhibits high affinity for ACh receptor sites and competitively blocks access of ACh to motor end-plate of myoneural junction; may affect ACh release.^{100 c}

• Blocks the effects of both the small quantities of ACh that maintain muscle tone and the large quantities of ACh that produce voluntary skeletal muscle contraction; does not alter the resting electrical potential of the motor end-plate or cause muscular contractions.^c

• Produces little or no histamine release.^{b c}

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.¹⁰⁰

• Importance of informing clinician of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses (e.g., cardiovascular disease, neuromuscular disease).¹⁰⁰

• Importance of informing patients of other important precautionary information.¹⁰⁰ (See Cautions.)

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

Frequently asked questions

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