From the Guidelines
Pancuronium (Pav) should be administered at an initial IV bolus dose of 0.06-0.1 mg/kg, followed by maintenance doses of 0.01-0.02 mg/kg every 30-60 minutes as needed for patients requiring mechanical ventilation. Prior to administration, ensure adequate sedation and analgesia are established, as neuromuscular blocking agents like pancuronium provide paralysis without affecting consciousness or pain sensation 1.
Key Considerations
- Continuous monitoring of neuromuscular blockade using train-of-four stimulation is essential, targeting 1-2 twitches for adequate paralysis while avoiding complete suppression 1.
- Vital signs, ventilator parameters, and sedation levels should be closely monitored throughout treatment.
- Pancuronium is particularly useful in hemodynamically unstable patients as it may increase heart rate and blood pressure through vagolytic effects 1.
- Be aware that pancuronium has a relatively long duration of action (60-100 minutes) and is primarily eliminated by the kidneys, so dose adjustments are necessary in patients with renal impairment 1.
- Daily interruption of neuromuscular blockade should be considered when clinically appropriate to assess neurological status and prevent complications like critical illness polyneuromyopathy associated with prolonged use 1.
Patient Selection
- The majority of patients in an ICU who are prescribed an NMBA can be managed effectively with pancuronium 1.
- For patients for whom vagolysis is contraindicated (e.g., those with cardiovascular disease), NMBAs other than pancuronium may be used 1.
- Patients with significant hepatic or renal disease may require alternative NMBAs, such as cisatracurium or atracurium, due to their unique metabolism 1.
From the Research
Recommended Protocol for Using Pancuronium in Patients Requiring Mechanical Ventilation
The use of pancuronium (Pav) in patients requiring mechanical ventilation is a complex issue, with several studies highlighting the potential risks and benefits associated with its use.
- The study by 2 found that the use of pancuronium bromide in patients with acute respiratory failure requiring intubation and mechanical ventilation was associated with a peculiar neuromuscular disorder, characterized by persistent tetraparetic syndrome and/or peroneal palsy with a concomitant increase of serum creatine kinase (CK).
- Another study by 3 reported that 12 patients who were treated with artificial ventilation and pancuronium bromide developed severe tetraparesis with areflexia, sometimes combined with disturbances of the extraocular and facial muscles and diffuse muscular atrophy.
- In contrast, the study by 4 recommended pancuronium as the preferred neuromuscular blocking agent for most critically ill patients, while vecuronium was recommended for patients with cardiac disease or hemodynamic instability.
- The study by 5 found that neuromuscular paralysis with pancuronium in ventilated preterm infants with evidence of asynchronous respiratory efforts seemed to have a favourable effect on intraventricular hemorrhage and possibly on air leak.
Potential Risks and Complications
The use of pancuronium in patients requiring mechanical ventilation is associated with several potential risks and complications, including:
- Neuromuscular disorders, such as persistent tetraparetic syndrome and/or peroneal palsy 2, 3
- Increased risk of difficulty in weaning patients from the respirator 2
- Myopathic alterations and axonal degeneration 2
- Renal and hepatic disturbances 3
Monitoring and Assessment
To minimize the risks associated with the use of pancuronium in patients requiring mechanical ventilation, it is essential to: