- pancuronium bromide
POM: Prescription only medicine
This information is intended for use by health professionals
Pancuronium Bromide 2 mg/ml Solution for Injection
Each 1 ml contains 2 mg of pancuronium bromide.
Each 2 ml ampoule contains 4 mg of pancuronium bromide.
For the full list of excipients, see section 6.1.
Solution for injection.
Clear, colourless solution.
The active substance of pancuronium bromide is an amino steroid which effectively blocks transmission of motor nerve impulses to the striated muscle receptors. It is a non-depolarising neuromuscular blocking agent with a long duration of action and is used in the following indications:
As an adjuvant in surgical anaesthesia to obtain relaxation of skeletal muscles in a wide range of surgical procedures.
Use in intensive care as a non-depolarising neuromuscular blocker for the treatment of various pathologies e.g. intractable status asthmaticus and tetanus.
The use of a peripheral nerve stimulator is recommended for monitoring the neuromuscular block and recovery.
Initial dose: 50-80 micrograms/kg (intubation accomplished within 150-120 seconds) or 80-100 micrograms/kg (intubation accomplished within 120-90 seconds).
Incremental doses: 10-20 micrograms/kg
Initial dose: 60-100 micrograms/kg
Incremental doses: 10-20 micrograms/kg
Doses of pancuronium bromide in neonates up to one month of age must be carefully individualised since neonates are particularly sensitive to non-depolarising neuromuscular blocking agents.
Dosage 30-40 micrograms/kg initially I/V followed by 10-20 micrograms/kg thereafter.
If succinylcholine is used for intubation the administration of pancuronium bromide should be delayed until the patient has clinically recovered from the neuromuscular block induced by succinylcholine.
Following the administration of suxamethonium the dosage of pancuronium bromide may be considerably reduced:
Initial dose: 20-60 micrograms/kg
Incremental doses 10-20 micrograms/kg
Initial dose: 20-60 micrograms/kg
Incremental doses 10-20 micrograms/kg
The neuromuscular blocking activity of pancuronium bromide is prolonged in the elderly and lower doses may be necessary.
In obese patients doses of pancuronium bromide based on a mg/kg basis may lead to over dosage. Dosage must be adjusted according to response.
Pancuronium bromide is longer acting in the intensive care patient, and an intravenous dose of 60 micrograms/kg every one to one and a half hours, or even less frequently is usually adequate.
IMPAIRED LIVER AND RENAL FUNCTION:
Care must be exercised in patients with impaired liver or renal function. See section 4.4.
Hyperdiuresis may result in a decreased neuromuscular blocking effect.
In the control of tetanus, duration of pancuronium bromide relaxation probably depends upon the severity of the spasm, therefore duration of effect can be variable.
The duration of action depends upon the clinical condition of the patient and the dose administered, but in normal subjects receiving perioperative muscle relaxant doses the duration of action is usually 45-60 minutes.
Pancuronium bromide should not be mixed with other agents in the same syringe, or with solutions for intravenous infusions as a change in pH may cause precipitation.
Discard any unused solution.
Method of administration
Pancuronium bromide should be administered intravenously. It is not recommended to be given by infusion.
The dosage should be individualised as there is a wide variation in individual response to muscle relaxants. When determining the dose, the method of anaesthesia, expected duration of surgery, potential interaction with other drugs that are administered before and during anaesthesia and the condition of the patient should be taken into account.
Hypersensitivity to pancuronium or the bromide ion or to any of the excipients listed in section 6.1. Concurrent use of a depolarising neuromuscular blocking agent e.g. suxamethonium.
Anaphylactic reactions can occur following the administration of neuromuscular blocking agents. Precautions for treating such reactions should always be taken. (see section 4.8).
Particularly in the case of previous anaphylactic reactions to neuromuscular blocking agents, special precautions should be taken since allergic cross-reactivity to neuromuscular blocking agents has been reported (see section 4.8).
As with other neuromuscular blocking agents, residual neuromuscular blockade has been reported for pancuronium, which can lead to post-operative complications. Several studies have shown that use of neuromuscular blocking agents during anaesthesia could be associated with an increased risk of post-operative pulmonary complications. In order to prevent complications resulting from residual neuromuscular block, adherence to local clinical practice guidelines, including neuromuscular monitoring and use of neuromuscular blockade reversal agents where appropriate, is recommended.
Myopathy after long term administration of other non-depolarising neuromuscular blocking agents in the ICU in combination with corticosteroid therapy has been reported regularly. Therefore, for patients receiving both neuromuscular blocking agents and corticosteroids, the period of use of the neuromuscular blocking agent should be limited as much as possible.
As pancuronium bromide is excreted mainly in the renal system, the elimination half-life is prolonged in renal failure, resulting in a reduction in plasma clearance and prolonged duration of action.
The prolongation of half-life in patients with renal failure is often but not always associated with an extended duration of neuromuscular blockage. In these patients, the recovery from neuromuscular block may also be prolonged.
Impaired Hepatic/Biliary Tract Disease:
The duration of action may be prolonged in these conditions and resistance to neuromuscular blocking action of pancuronium bromide may occur because of the increased volume of distribution of the drug.
In such conditions, the drug has a slower onset and coupled with the increased total dosage requirements, there may be a prolongation of blockade and recovering time in these patients.
Patients with carcinomatosis especially associated with bronchial carcinoma may exhibit a marked sensitivity to this agent, and the neuromuscular block produced may respond poorly to neostigmine.
As with other non-depolarising muscle relaxants pancuronium bromide should be used with care in patients with pre-existing pulmonary, hepatic or renal disease and with particular care in patients with muscular dystrophies, myasthenia gravis and myasthenic syndrome unless it is intended to administer prolonged post-operative respiratory assistance. As is the case with other curariform agents, in cases of neuromuscular disease or after poliomyelitis, pancuronium bromide should be used with extreme caution since the response to neuromuscular blocking agents may be considerably altered in these patients. The magnitude and direction of this alteration may vary widely.
Before administration of pancuronium bromide conditions such as electrolyte disturbance, altered pH, and dehydration should be corrected if possible. Pancuronium bromide should be used cautiously in patients with a tendency to hypertension.
Pancuronium bromide can cause a reduction in the partial prothromboplastin time and prothrombin time. Conditions associated with slower circulation times, e.g. cardiovascular disease, oedema, old age result in an increased volume of distribution which may lead to an increased onset time.
Pancuronium bromide should be used with particular care in neonates, in ill or cachetic patients, in the presence of liver disease or obstructive jaundice (resistant to the effects of drugs) in states with altered plasma protein levels or when there is diminished renal blood flow or renal disease. In operations employing the hypothermic techniques the neuromuscular blocking effect of non-depolarising drugs is decreased and increased by warming the patient.
Pancuronium bromide should be administered in carefully adjusted dosage or under the supervision of a qualified anaesthetist and only when facilities for controlled ventilation, insufflation with oxygen and endotracheal intubation are available for immediate use.
Since pancuronium bromide causes relaxation of the respiratory muscles, respiration must be assisted in all patients. It is essential to ensure that the patient is breathing spontaneously, deeply and regularly before leaving the theatre after anaesthesia. The neuromuscular blockage achieved with pancuronium bromide can be reversed with a cholinesterase inhibiting agent (e.g. neostigmine) in an adequate dose, together with atropine as an anticholinergic agent.
Care should be exercised if there is a danger of regurgitation when intubating the patient, for example during crash induction.
Other conditions which may increase the effect of pancuronium bromide are: hypokalaemia (e.g. after severe vomiting, diarrhoea, digitalisation and diuretic therapy), hypomagnesaemia, hypocalcaemia (after massive transfusions), hypoproteinaemia, dehydration, acidosis, hypercapnia and cachexia.
This medicine contains less than 1 mmol sodium (23 mg) per ampoule, that is to say essentially 'sodium-free'.
Suxamethonium. Used prior to pancuronium bromide (for endotracheal intubation) enhances the relaxation effect of the pancuronium bromide and the duration of action. Therefore administration of pancuronium bromide should be delayed until suxamethonium shows signs of wearing off.
Anaesthetics. The following anaesthetics may potentiate the neuromuscular blocking activity of pancuronium bromide: halothane, ether, enflurane, isoflurane, methoxyflurane, cyclopropane, thiopentone, methohexitone, ketamine, fentanyl, gammahydroxybutyrate, etomidate.
The following drugs may influence the duration of action of pancuronium bromide and the intensity of neuromuscular block.
Potentiation: Other non-depolarising muscle relaxants, prior administration of succinylcholine, antibiotics of the polypeptide and aminoglycoside groups, diazepam, propranolol, thiamine (high dose), MAO inhibiting agents, quinidine, magnesium sulfate, protamine, nitroglycerin, narcotic analgesics, diuretics, phenytoin, alpha and beta adrenergic blocking agents, imidazoles, metronidazole, noradrenaline and adrenaline.
Decreased effect: Neostigmine, edrophonium, corticosteroids (high dose), noradrenaline, adrenaline, potassium chloride, calcium chloride, sodium chloride, heparin (temporary decrease), azathioprine, theophylline, pyridostigmine, neuroleptic analgesia and propanidid.
Variable effect: Depolarising muscle relaxants given after the administration of pancuronium bromide may produce potentiation or attenuation of the neuromuscular blocking effect.
The non-depolarising drug increases resistance towards the neuromuscular blocking effect of the depolarising drug. Therefore high doses of a depolarising drug are necessary before muscular relaxation can be obtained. These high doses of a depolarising drug may cause endplate desensitisation and prolong post-operative apnoea.
Unlike a non-depolarising block, a depolarising block cannot be overcome by, and may even be worsened by an anticholinesterase agent.
The duration of action of mivacurium has been found to be significantly increased when given after pancuronium bromide, due to the reduction of plasma cholinesterase activity by pancuroniumbromide.
Several studies have attributed the occurrence of acute myopathy in Intensive Care Unit patients to the combination of corticosteroids and neuromuscular blocking agents.
Influence on the cardiovascular system: Pancuronium bromide does not intensify the hypotension induced by halothane; in addition the cardiac depression is partly restored. The excessive bradycardia induced by neuroleptic analgesia and some of the cholinergic effects of morphine derivatives are counteracted by pancuronium bromide.
Pancuronium bromide should be given with caution to patients receiving chronic tricyclic antidepressant therapy who are anaesthetised with halothane or any inhalation anaesthetic since this enhances the predisposition to the development of cardiac arrhythmias associated with tricyclic antidepressants.
Recent evidence suggests that alkylating drugs (nitrogen mustards) should be considered a possible hazard when given to patients during anaesthesia involving the use of muscle relaxants.
The use of pancuronium bromide in pregnant or breast feeding women with respect to safety has not been established. Therefore the drug should only be administered to pregnant women or lactating women when the attending physician decides that the potential benefits outweigh the risks.
Pancuronium bromide may be used for caesarean section. Pancuronium bromide does not affect Apgar score, foetal muscle tonus nor cardiorespiratory adaptation of the new-born. From assays of pancuronium bromide concentration in umbilical blood samples it is apparent that only very limited placental transfer of pancuronium bromide occurs.
The reversal of neuromuscular block induced by pancuronium bromide may be unsatisfactory in patients receiving magnesium sulfate for toxaemia of pregnancy because magnesium salts enhance neuromuscular blockade. Dosages should be reduced in such cases.
It is not recommended to use potentially dangerous machinery or drive a car within 24 hours after full recovery from the neuromuscular blocking action of pancuronium bromide.
High doses of a depolarising drug may cause end-plate desensitisation and prolong post-operative apnoea.
Cardiac disorders and vascular disorders: Increased pulse rate and cardiac output. Blood pressure may rise. Arrhythmias may occur occasionally.
Eye disorders: Pancuronium bromide decreases intra-ocular pressure and induces miosis, both effects being favourable in ophthalmic surgery.
Gastrointestinal disorders: Salivation is sometimes noted during anaesthesia.
Musculoskeletal and connective tissue disorders: Myopathy has been reported (frequency not known / cannot be estimated from the available data) after the use of various neuromuscular blocking agents in the ICU in combination with corticosteroids (see section 4.4).
Skin and subcutaneous tissue disorders: Occasional transient rash has been noted.
Immune system disorders: Hypersensitivity
Severe anaphylactoid reactions have been reported uncommonly. In the case of previous anaphylactic reactions to neuromuscular blocking agents, special precautions should be taken since allergic cross reactivity between neuromuscular blocking agents has been reported.
Since neuromuscular blocking agents in general are known to be capable of inducing histamine release both locally and systemically, the possible occurrence of itching and erythematous reactions at the site of injection and/or generalised histaminoid (anaphylactoid) reactions such as bronchospasm and cardiovascular changes should always be taken into consideration when administering these drugs.
General disorders and administration site conditions: Injection Site Reactions: Pain or local skin reactions noted at the site of injection.
Respiratory disorders: Bronchospasm has rarely been reported.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.
Clinical features: The symptoms are those of prolonged apnoea, respiratory depression and/or muscle weakness. Death may follow acute respiratory failure.
Management: Neostigmine (2.5 mg) administered with atropine (1.2 mg) or glycopyrrolate, can be used to reverse the neuromuscular block while ventilation is continued. When administration of the cholinesterase inhibiting agent fails to reverse the neuromuscular blocking effects of pancuronium bromide ventilation must continue until spontaneous breathing is restored. Repeated dosage of cholinesterase inhibitor can be dangerous.
Pharmacotherapeutic group: Muscle relaxants, peripherally acting agents, other quaternary ammonium compounds, ATC code: M03AC01.
Mechanism of action
Pancuronium bromide produces pharmacologic effects similar to those of other non-depolarising neuromuscular blocking agents. The drug may produce an increase in heart rate which appears to result from a direct blocking effect on the acetylcholine receptors of the heart. The increase in heart rate appears to be dose related and is minimal with usual doses. Pancuronium bromide causes little or no histamine release and no ganglionic blockade and therefore does not cause hypotension or bronchospasm. Despite its steroidal structure, the drug exhibits no hormonal activity.
Following I/V administration of pancuronium bromide 60 micrograms /kg, muscle relaxation reaches a level suitable for endotracheal intubation within 2-3 minutes, slightly more rapidly than with tubocurarine. The onset and duration of paralysis are dose related. After a dose of 60 micrograms/kg, the effects of the drug begin to subside in about 35-45 minutes. Supplemental doses may increase the magnitude and duration of the neuromuscular blockade. The duration of action depends upon the clinical condition of the patient and the dose administered, but in normal subjects receiving perioperative muscle relaxant doses the duration of action is usually 45-60 minutes.
Protein binding of pancuronium bromide does not appear to be substantial. The activity of the drug is not greatly affected by plasma carbon dioxide concentrations or pH. Redistribution is responsible for the termination of activity following single doses. Pancuronium bromide crosses the placenta in small amounts.
Plasma concentrations appear to decline in a triphasic manner. In adults with normal renal and hepatic function, the half-life in the terminal phase is about 2 hours. The elimination half-life may be prolonged in patients with impaired renal and/or hepatic function. The drug is eliminated mainly unchanged by the kidneys, although small amounts may be metabolised and some of the drug may be eliminated in the bile.
Water for injections
Do not mix other solutions in the same syringe as a change in pH can cause precipitation.
Store in a refrigerator (2°C-8°C). Do not freeze. Keep the ampoule in the outer carton in order to protect from light.
2ml Type I clear glass ampoules.
Pack sizes of 5, 10 and 50.
Not all pack sizes may be marketed.
For single use only. Discard any unused contents. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
Hospira UK Limited
Date of first authorisation: 07/02/1997
Date of last renewal: 12/02/2003
Ref: gxPU 7_0
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