pancuronium bromide

Muscle Relaxants, Peripherally Acting

Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
Accidental administration of neuromuscular blocking agents can be fatal. Store pancuronium with the cap and ferrule intact, in a manner that minimizes the possibility of selecting the wrong product.

Only experienced clinicians, familiar with the use of neuromuscular blocking drugs, should administer or supervise the use of pancuronium. Adequacy of respiration must be assured through assisted or controlled ventilation.
To avoid distress to the patient, pancuronium should be administered only after unconsciousness has been induced. Adequate amnesia, sedation, and analgesia should accompany neuromuscular blockade.[41961]
 
Intermittent IV Injection
No further dilution necessary.
Administer by direct IV injection over seconds.[52572]
 
Continuous IV Infusion
NOTE: Due to pancuronium's long duration of action, the use of shorter-acting agents is preferred when continuous infusion is the desired method of drug administration.
Dilute to a concentration of 0.01 to 0.8 mg/mL in a compatible IV infusion solution (i.e., 0.9% Sodium Chloride Injection, 5% Dextrose Injection, 5% Dextrose and 0.9% Sodium Chloride Injection, or Lactated Ringer's Injection).[41961] [52572]
Infuse at a rate based on patient response and requirements.
A peripheral nerve stimulator is recommended to monitor pancuronium's effects. Target response is typically 1 to 2 twitches. Incorrect electrode placement, direct stimulation of muscle due to large electrode size, acute illness, capillary leak, and edema may affect an appropriate assessment. Monitor visual and tactile stimulation on muscle movement as well as heart rate, blood pressure, and mechanical ventilator status during administration.[41961] [52441]
Storage: Dilution is stable for 48 hours at room temperature.[41961]

anaphylactoid reactions / Rapid / Incidence not known
bronchospasm / Rapid / Incidence not known
angioedema / Rapid / Incidence not known
malignant hyperthermia / Rapid / Incidence not known
muscle paralysis / Delayed / Incidence not known
acute quadriplegic myopathy syndrome / Delayed / Incidence not known
apnea / Delayed / Incidence not known
thrombosis / Delayed / Incidence not known
keratitis / Delayed / Incidence not known

wheezing / Rapid / Incidence not known
hypotension / Rapid / Incidence not known
erythema / Early / Incidence not known
hypoxia / Early / Incidence not known
dyspnea / Early / Incidence not known
respiratory depression / Rapid / Incidence not known
myopathy / Delayed / Incidence not known
conjunctivitis / Delayed / Incidence not known
skin erosion / Delayed / Incidence not known
skin ulcer / Delayed / Incidence not known
sinus tachycardia / Rapid / Incidence not known
hypertension / Early / Incidence not known
tolerance / Delayed / Incidence not known

pruritus / Rapid / Incidence not known
rash / Early / Incidence not known
flushing / Rapid / Incidence not known
urticaria / Rapid / Incidence not known
weakness / Early / Incidence not known
xerophthalmia / Early / Incidence not known
anxiety / Delayed / Incidence not known
hypersalivation / Early / Incidence not known

Pancuronium administration requires an experienced clinician who is familiar with its actions and the possible complications that may occur after its use as well as requires a specialized care setting where facilities for intubation, artificial respiration, oxygen therapy, and reversal agents are immediately available. Accidental exposure to a neuromuscular blocking agent may be fatal in a patient for whom it is not intended. Store pancuronium with cap and ferrule intact and in a manner that minimizes the possibility of selecting the wrong product. Confirm proper medication selection and clearly communicate the intended dose.[41961]

Rx

Parenteral, long-acting, nondepolarizing, neuromuscular blocking agent
Used for an adjunct to general anesthesia to facilitate tracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation
Minimal histamine release; associated with tachycardia and hypertension due to vagolytic properties

0.05 to 0.1 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.05 to 0.15 mg/kg/dose IV every 4 to 6 hours as needed; adjust dose and interval to patient's twitch response. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.05 to 0.1 mg/kg/dose IV every 4 to 6 hours as needed; adjust dose and interval to patient's twitch response. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.05 to 0.1 mg/kg/dose IV every 4 to 6 hours as needed; adjust dose and interval to patient's twitch response. Consider a test dose of 0.02 mg/kg to measure responsiveness. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.06 to 0.1 mg/kg IV bolus, followed by 0.8 to 2 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.15 mg/kg IV bolus, followed by 0.5 to 1 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.1 mg/kg IV bolus, followed by 0.4 to 0.6 mcg/kg/minute continuous IV infusion; titrate to patient's twitch response. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.04 to 0.1 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response. Later incremental doses starting at 0.01 mg/kg may be used. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.04 to 0.1 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response. Later incremental doses starting at 0.01 mg/kg may be used. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.04 to 0.1 mg/kg/dose IV as needed; adjust dose and interval to patient's twitch response. Consider a test dose of 0.02 mg/kg to measure responsiveness. Later incremental doses starting at 0.01 mg/kg may be used. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

0.06 to 0.1 mg/kg/dose IV. Onset of intubating conditions is 2 to 3 minutes. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[41961]

0.06 to 0.1 mg/kg/dose IV. Usual dose: 0.1 mg/kg/dose. Onset of intubating conditions is 2 to 5 minutes. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.[41961] [44771]

0.05 to 0.1 mg/kg/dose IV. Consider a test dose of 0.02 mg/kg to measure responsiveness. Onset of intubating conditions is 1 to 3 minutes. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.

Limited data; 0.1 mg/kg/dose IV every 2 hours. Guidelines suggest that neuromuscular blocking agents may be used to manage overt shivering in therapeutic hypothermia.

Limited data; 0.01 to 0.1 mg/kg/hour continuous IV infusion. Guidelines suggest that neuromuscular blocking agents may be used to manage overt shivering in therapeutic hypothermia.

†Indicates off-label use

Specific guidelines for dosage adjustments in hepatic impairment are not available. Consider the possibility of slower onset, higher total dosage, and prolongation of neuromuscular blockade when pancuronium is used in patients with hepatic disease and/or biliary tract disease.

Specific guidelines for dosage adjustments in adult patients with renal impairment are not available. If pancuronium is used in a patient with renal failure, consider that the rate of recovery of neuromuscular blockade is variable and sometimes very much slower than normal.[41961]
 
Pediatric patients
CrCl more than 50 mL/minute/1.73 m2: No initial dosage adjustment required; monitor carefully and adjust dosage to clinical effect.
CrCl 10 to 50 mL/minute/1.73 m2: Administer 50% of normal dosage; monitor carefully and adjust dosage to clinical effect.
CrCl less than 10 mL/minute/1.73 m2: Avoid use.[32569]

Acebutolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Acetazolamide: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
Aliskiren; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Aliskiren; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amide local anesthetics: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Aminoglycosides: (Moderate) Concomitant use of neuromuscular blockers and systemic aminoglycosides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Atorvastatin: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Benazepril: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Celecoxib: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Olmesartan: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Valsartan: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amlodipine; Valsartan; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Amphotericin B cholesteryl sulfate complex (ABCD): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Amphotericin B lipid complex (ABLC): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Amphotericin B liposomal (LAmB): (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Amphotericin B: (Moderate) Monitor serum potassium concentrations with concomitant use of neuromuscular blockers and amphotericin B. Amphotericin B-induced hypokalemia may prolong neuromuscular blockade.
Atenolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Atenolol; Chlorthalidone: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Bacitracin: (Minor) Concomitant use of neuromuscular blockers and systemic bacitracin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bendroflumethiazide; Nadolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Beta-blockers: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Betaxolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Bismuth Subcitrate Potassium; Metronidazole; Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bismuth Subsalicylate; Metronidazole; Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Bisoprolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Bisoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Botulinum Toxins: (Moderate) Use neuromuscular blockers and botulinum toxins concurrently with caution because the effect of the botulinum toxin may be potentiated. If coadministered, observe the patient closely.
Brimonidine; Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Calcium Acetate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Famotidine; Magnesium Hydroxide: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Magnesium Hydroxide: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Magnesium Hydroxide; Simethicone: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Risedronate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Carbonate; Simethicone: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Chloride: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium Gluconate: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium; Vitamin D: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Calcium-channel blockers: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Capreomycin: (Minor) Concomitant use of neuromuscular blockers and capreomycin may prolong neuromuscular blockade. A partial neuromuscular blockade was demonstrated after large intravenous doses of capreomycin.
Carbonic anhydrase inhibitors: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
Carteolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Carvedilol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Chromium: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Clevidipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Colistimethate, Colistin, Polymyxin E: (Moderate) Use neuromuscular blockers and polymyxins with extreme caution. Concomitant use of neuromuscular blockers and polymyxins may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Colistin: (Moderate) Use neuromuscular blockers and polymyxins with extreme caution. Concomitant use of neuromuscular blockers and polymyxins may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Corticosteroids: (Moderate) Limit the period of use of neuromuscular blockers and corticosteroids and only use when the specific advantages of the drugs outweigh the risks for acute myopathy. An acute myopathy has been observed with the use of high doses of corticosteroids in patients receiving concomitant long-term therapy with neuromuscular blockers. Clinical improvement or recovery after stopping therapy may require weeks to years.
Cyclosporine: (Moderate) Concomitant use of neuromuscular blockers and cyclosporine may prolong neuromuscular blockade.
Demeclocycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Desflurane: (Moderate) Concomitant use of pancuronium and desflurane may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration. During maintenance of desflurane anesthesia, the pancuronium dose is likely to be reduced compared to that during nitrous oxide/opioid anesthesia. For endotracheal intubation, do not reduce the dose of pancuronium. Anesthetic concentrations of desflurane at equilibrium (administered for 15 or more minutes before testing) reduced the ED95 of pancuronium by approximately 50% compared to nitrous oxide/opioid anesthesia.
Dextromethorphan; Quinidine: (Moderate) Concomitant use of neuromuscular blockers and quinidine may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Digoxin: (Moderate) Use pancuronium with caution in patients receiving digoxin due to an increased risk of dysrhythmia.
Diltiazem: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Donepezil: (Moderate) A higher pancuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as donepezil.
Donepezil; Memantine: (Moderate) A higher pancuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as donepezil.
Dorzolamide; Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Doxapram: (Minor) Doxapram may temporarily mask the residual effects of neuromuscular blockers.
Doxycycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Enalapril; Felodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Enflurane: (Major) Reduce the initial pancuronium dose if pancuronium is first administered after establishment of steady-state enflurane anesthesia. Consider the relatively long duration of action of pancuronium when the drug is selected for intubation in these circumstances. The neuromuscular blocking action of pancuronium is potentiated by enflurane anesthesia. Recommended initial doses of pancuronium may be used to facilitate tracheal intubation before administration of enflurane.
Entecavir: (Moderate) Monitor patients receiving pancuronium and entecavir closely. Coadministration may increase serum concentrations of either drug due to competition for elimination via active tubular secretion.
Esmolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Ester local anesthetics: (Moderate) Concomitant use of neuromuscular blockers and local anesthetics may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Felodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Fosphenytoin: (Moderate) Concomitant use of neuromuscular blockers and fosphenytoin may increase resistance to the neuromuscular blockade action of neuromuscular blockers, resulting in shorter durations of neuromuscular blockade and higher infusion rate requirements. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Galantamine: (Moderate) A higher pancuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as galantamine.
Indapamide: (Moderate) Concomitant use of neuromuscular blockers and indapamide may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Irinotecan Liposomal: (Moderate) Irinotecan may antagonize the neuromuscular blocking effects of pancuronium due to anticholinesterase activity.
Irinotecan: (Moderate) Irinotecan may antagonize the neuromuscular blocking effects of pancuronium due to anticholinesterase activity.
Isoflurane: (Major) Reduce the initial pancuronium dose if pancuronium is first administered after establishment of steady-state isoflurane anesthesia. Consider the relatively long duration of action of pancuronium when the drug is selected for intubation in these circumstances. The neuromuscular blocking action of pancuronium is potentiated by isoflurane anesthesia. Recommended initial doses of pancuronium may be used to facilitate tracheal intubation before administration of isoflurane.
Isradipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Ketorolac: (Minor) There have been postmarketing reports of a possible interaction between ketorolac and nondepolarizing neuromuscular blockers, such as pancuronium, that resulted in apnea.
Labetalol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Levamlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Levobetaxolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Levobunolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Lincosamides: (Moderate) Use neuromuscular blockers and lincosamides with caution. Concomitant use of neuromuscular blockers and lincosamides may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Lithium: (Moderate) Concomitant use of neuromuscular blockers and lithium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Loop diuretics: (Moderate) Concomitant use of neuromuscular blockers and loop diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Magnesium: (Moderate) Concomitant use of neuromuscular blockers and magnesium may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Methazolamide: (Moderate) Nondepolarizing neuromuscular blockers when combined with carbonic anhydrase inhibitors may lead to prolonged respiratory depression. This action is due to enhanced neural blockade as a result of potential hypokalemia from the carbonic anhydrase inhibitor. Serum potassium concentrations should be checked and adjusted prior to the administration of nondepolarizing neuromuscular blockers.
Metoprolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Metoprolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Minocycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Nadolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Nebivolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Nebivolol; Valsartan: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Neostigmine: (Moderate) A higher pancuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as neostigmine. Intravenous neostigmine is indicated for reversal of the effects of nondepolarizing neuromuscular blockers, such as pancuronium.
Nicardipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Nifedipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Nimodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Nisoldipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Olmesartan; Amlodipine; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Omadacycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Penbutolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Perindopril; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Phenytoin: (Moderate) Concomitant use of neuromuscular blockers and phenytoin may increase resistance to the neuromuscular blockade action of neuromuscular blockers, resulting in shorter durations of neuromuscular blockade and higher infusion rate requirements. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Physostigmine: (Moderate) A higher pancuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as physostigmine.
Pindolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Piperacillin: (Moderate) Concomitant use of pancuronium and piperacillin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Piperacillin; Tazobactam: (Moderate) Concomitant use of pancuronium and piperacillin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Polymyxin B: (Major) Avoid concomitant use of systemic polymyxin B and neuromuscular blockers due to the risk of respiratory depression. The neurotoxicity of polymyxin B may can result in neuromuscular blockade, especially when given soon after neuromuscular blockers. If signs of respiratory paralysis appear, assist respiration and discontinue drug therapy.
Procainamide: (Moderate) A lower neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant procainamide use due to procainamide effects on reducing acetylcholine release. Concomitant use of neuromuscular blockers and procainamide may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Propranolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Propranolol; Hydrochlorothiazide, HCTZ: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Pyridostigmine: (Moderate) A higher pancuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as pyridostigmine. Intravenous pyridostigmine is indicated for reversal of the effects of nondepolarizing neuromuscular blockers, such as pancuronium.
Pyridoxine, Vitamin B6: (Moderate) Concomitant use of neuromuscular blockers and calcium may result in resistance to neuromuscular blockade. Calcium antagonizes the potentiating effect of magnesium on neuromuscular blockade. Also, calcium triggers acetylcholine release, and therefore, may both reduce the sensitivity to neuromuscular blockers and decrease the duration of neuromuscular blockade.
Quinidine: (Moderate) Concomitant use of neuromuscular blockers and quinidine may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Quinine: (Major) Avoid concomitant use of neuromuscular blockers and quinine. Quinine may enhance the action of neuromuscular blockers. In 1 patient who received a neuromuscular blocker during an operative procedure, subsequent administration of quinine 1,800 mg 3 hours later resulted in respiratory depression.
Ranitidine: (Moderate) Ranitidine may cause resistance to pancuronium-induced neuromuscular blockade, due to pharmacodynamic alterations at the acetylcholine receptor. In vitro studies demonstrate that therapeutic serum concentrations of ranitidine inhibit acetylcholinesterase, thus increasing the amount of acetylcholine available to compete at the neuromuscular junction and reverse the neuromuscular blockade. The inhibition of acetylcholinesterase is likely dose-related. Resistance to nondepolarizing neuromuscular blockers was reported occasionally with intravenous ranitidine dosages that were slightly higher than those given clinically, but not frequently with oral therapy.
Rivastigmine: (Moderate) A higher pancuronium dose may be required to achieve neuromuscular block with concomitant use of a cholinesterase inhibitor, such as rivastigmine.
Sarecycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Sevoflurane: (Moderate) Reduce the initial pancuronium dose if pancuronium is first administered after establishment of steady-state sevoflurane anesthesia. Consider the relatively long duration of action of pancuronium when the drug is selected for intubation in these circumstances. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration. The neuromuscular blocking action of pancuronium is potentiated by sevoflurane anesthesia. Recommended initial doses of pancuronium may be used to facilitate tracheal intubation before administration of sevoflurane.
Sotalol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Succinylcholine: (Major) If succinylcholine is used before pancuronium, delay pancuronium administration until recovery from succinylcholine-induced neuromuscular blockade begins. Prior administration of succinylcholine may enhance the neuromuscular blocking effect of pancuronium and increase its duration of action. If a small dose of pancuronium is given at least 3 minutes before administration of succinylcholine, in order to reduce the incidence and intensity of succinylcholine-induced fasciculations, this dose may induce a degree of neuromuscular block sufficient to cause respiratory depression in some patients.
Telmisartan; Amlodipine: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Tetracycline: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Tetracyclines: (Moderate) Concomitant use of neuromuscular blockers and tetracyclines may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Theophylline, Aminophylline: (Moderate) A higher neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant aminophylline use. Aminophylline may antagonize neuromuscular blocking effects, possibly due to phosphodiesterase inhibition. (Moderate) A higher neuromuscular blocker dose may be required to achieve neuromuscular block with concomitant theophylline use. Theophylline may antagonize neuromuscular blocking effects, possibly due to phosphodiesterase inhibition.
Thiazide diuretics: (Moderate) Concomitant use of neuromuscular blockers and thiazide diuretics may prolong neuromuscular blockade, possibly due to hypokalemia or alterations in potassium concentrations across the end-plate membrane.
Timolol: (Moderate) Concomitant use of neuromuscular blockers and beta-blockers may prolong neuromuscular blockade.
Trandolapril; Verapamil: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.
Trospium: (Moderate) Monitor patients receiving pancuronium and trospium closely. Coadministration may increase serum concentrations of either drug due to competition for elimination via active tubular secretion.
Vancomycin: (Moderate) Concomitant use of neuromuscular blockers and vancomycin may prolong neuromuscular blockade. The use of a peripheral nerve stimulator is strongly recommended to evaluate the level of neuromuscular blockade, to assess the need for additional doses of neuromuscular blocker, and to determine whether adjustments need to be made to the dose with subsequent administration.
Verapamil: (Moderate) Concomitant use of neuromuscular blockers and calcium-channel blockers may prolong neuromuscular blockade.

Pancuronium Bromide Intravenous Inj Sol: 1mg, 1mL, 2mg

Specific maximum dosage information is not available. Dosage must be individualized based on clinical response.

Muscle contraction is initiated by an action potential traveling from the central nervous system to the nerve terminal. At the nerve terminal, the action potential causes an influx of calcium, initiating release of acetylcholine (ACh) into the synaptic cleft. ACh binds to ACh receptors on the muscle fiber's motor end-plate causing a conformational change that briefly opens sodium ion channels. When an adequate number of ACh receptors are activated, membrane potential decreases and voltage-dependent sodium ion channels of adjacent muscle membranes activate, transmitting the action potential throughout the muscle fiber and resulting in muscle contraction.[52452] Nondepolarizing neuromuscular blocking agents (NMBAs) such as pancuronium produce skeletal muscle paralysis by competing with ACh for cholinergic receptor sites at the motor end-plate.[52486] Neuromuscular blockade progresses in a predictable order, beginning with muscles associated with fine movements (e.g., eyes, face, and neck), followed by muscles of the limbs, chest, and abdomen and, finally, the diaphragm. Larger doses increase the chance of respiratory depression associated with relaxation of the intercostal muscles and the diaphragm. Muscle tone returns in the reverse order.[52503]
 
Pancuronium is a bisquaternary aminosteroid. In addition to its therapeutic actions, pancuronium can cause an increase in heart rate and blood pressure due to vagolytic and weak sympathomimetic properties. Pancuronium produces little histamine release and no ganglion blockade, so hypotension and bronchospasm are not associated with its use.[52503] [52565]

Pancuronium is administered intravenously. Protein binding is approximately 87%, primarily to gamma globulin and albumin.[41961] After administration, pancuronium distributes to the extracellular space.[52463] Vd ranges from 0.24 to 0.28 L/kg in adult patients, which is similar to that of children (0.2 L/kg).[41961] [52463] Plasma clearance is approximately 1.1 to 1.9 mL/kg/minute in both pediatric and adult patients. Metabolism occurs via hepatic pathways to at least 3 metabolites. Up to 25% of an administered pancuronium dose is recovered as the 3-hydroxy metabolite, which is approximately half as potent as the parent drug. Less than 5% of the administered dose is recovered as the 17-hydroxy and 3, 17-hydroxy metabolites, both of which are 50 times less potent than pancuronium. Of a pancuronium dose, 40% is excreted in the urine and 11% in the bile. Elimination half-life ranges from 89 to 161 minutes.[41961]
 
Affected cytochrome P450 isoenzymes and drug transporters: none

In general, neuromuscular blockade begins within 2 to 3 minutes, peaks in approximately 4 minutes, and persists 22 to 100 minutes in adults. Intensity and duration of action are affected by the dose, age of the patient, and the use of concurrent anesthetics and other neuromuscular blocking agents.

There are limited data regarding the use of pancuronium during breast-feeding. The elimination half-life for pancuronium is 1.5 to 3 hours. It is a bisquaternary ammonium compound and should pass slowly through biological membranes. Due to poor oral absorption and poor lipid solubility, it is not likely that pancuronium would reach the infant's bloodstream. Based on these data, breast-feeding could be allowed as soon as practically feasible after surgery.