Vecuronium Bromide

Brand names Norcuron, generic

Medication error ISMP high-alert medication that has an increased risk of causing significant patient harm potential if it is used in error.(1) Look-alike, sound-alike drug names USP reports that vecuronium has been confused with pancuronium and rocuronium; no patient harm resulted. USP reports that vecuronium has been confused with vanco- mycin; patient harm resulted. USP also reports that vecuronium has been confused with Zemuron; patient death resulted.(2) ISMP and USP report that Norcuron has been confused with Narcan; no patient harm resulted.(2,3) USP also reports that Norcuron has been confused with Natrecor; patient death resulted.(2)

Contraindications U.S. boxed warning: Vecuronium should be administered only by adequately trained and warnings individuals familiar with its actions, characteristics, and hazards.(4) Contraindications: Hypersensitivity to vecuronium or any of its components.(4) Other warnings: Use carefully under the supervision of experienced clinicians; personnel should be skilled in airway management, resuscitation, and respiratory support. Intubation and ventilatory support equipment, including oxygen therapy, should be readily available. Reversal agents should be readily available when giving vecuronium.(4)

Infusion-related Flushing, erythema, pruritus, urticaria, bronchospasm, and hypotension are uncommon cautions but may occur.(4,5) In one study, 69% of patients with confirmed rocuronium allergy demonstrated cross- sensitivity to vecuronium.(6)

Dosage Respiratory function must be supported during use of this agent. Concurrent administration of a sedative is also necessary. Monitoring of neuromuscular transmission with a peripheral nerve stimulator is recommended during continuous infusion or with repeated dosing.(4,7) Because vecuronium does not cause histamine release, it is considered the neuromuscular blocking agent of choice in patients with allergies and/or asthma.(8,9) Dosing adjustment for hypothermia: During moderate-to-deep hypothermia dur- ing cardiopulmonary bypass (lowest nasopharyngeal temperature range 17°C to 29°C), vecuronium infusion requirements decreased by 84% to 92% in order to maintain a constant level of blockade.(10) Dosing adjustment for obesity: Doses should be based on ideal body weight.(11) Authors of an opinion-based review on dosing adjustments of anesthetic agents in morbidly obese patients recommend vecuronium be dosed using ideal body weight to avoid prolonged duration of paralysis.(33) Pediatric consensus guidelines also recommend using ideal body weight for vecuronium dosing.(34) Induction and maintenance of neuromuscular blockade Neonates: 0.1 mg/kg for nonemergent intubation.(12) (See Other in the Comments section.) Initial dose 0.02–0.1 mg/kg(13,14); may be repeated as needed to maintain desired neuromuscular blockade. Maintenance doses during general anesthesia may need to be reduced to 0.01–0.015 mg/kg.(4) Continuous infusions of 0.07–0.18 mg/kg/hr (1.2–3 mcg/kg/min) have been reported.(14) Infants, children, and adolescents: Initial dose 0.05–0.1 mg/kg(4,8,13-17); American Academy of Pediatrics (AAP) recommends 0.2 mg/kg for intubation.(18) Doses may be repeated as needed to maintain desired neuromuscular blockade. Maintenance doses during general anesthesia may need to be reduced to 0.01–0.015 mg/kg.(4) Continuous infusions range from 0.05–0.15 mg/kg/hr (0.8–2.5 mcg/kg/min).(4,8,14,15,17)  864 Vecuronium Bromide

Dosage adjustment To avoid prolonged neuromuscular blockade, give smaller initial doses to anephric patients. in organ dysfunction Patients with cirrhosis and cholestasis may experience prolonged recovery times.(4)

Maximum dosage A single dose of 0.4 mg/kg has been used safely in children 2–9 years old with normal renal and hepatic function.(16) The largest reported continuous infusion rate was 0.27 mg/kg/hr (4.5 mcg/kg/min) for 21 hours.(14)

Additives If bacteriostatic water for injection is used to reconstitute vecuronium, the resulting solu- tion will contain benzyl alcohol.(4,19) (See Appendix C for more specific information about potential adverse effects and/or benzyl alcohol toxicity in neonates.)

Suitable diluents D5W, D5NS, NS, LR(4,19)

Maximum 1 mg/mL(4,19) concentration

Preparation and Parenteral products should be visually inspected for particulate matter and discoloration delivery before use. Refer to appropriate references for more information on compatibility with other drugs and solutions, compatibility following Y-site delivery, and suggested storage and extended stability.(19) In neonates, use SW for reconstitution to avoid the administration of benzyl alcohol.(19) Vecuronium should not be mixed or administered with alkaline solutions.(4)

IV push 1 mg/mL administered rapidly over seconds(4,19)

Intermittent infusion Not generally recommended.(4) An intermittent regimen (0.1 mg/kg q 1 hr) was com- pared to a continuous infusion regimen (bolus of 0.15 mg/kg followed by 0.06 mg/kg/hr [1 mcg/kg/min]) in 12 patients ages 3 weeks to 13.5 years. The continuous infusion regimen resulted in significantly less cumulative vecuronium administration.(15)

Continuous infusion 0.1–0.2 mg/mL preferred.(4,14,17,19) In fluid-restricted patients, 0.4 mg/mL was used in one study.(14) Another reference states that up to 1 mg/mL may be given via continuous infusion.(20)

Other routes of Should not be given IM.(4,19) No information is available to support administration by other administration routes.

Comments Significant adverse effects: Prolonged paralysis has been reported in several patients after long-term infusion of vecuronium.(21-23) Acute quadriplegic myopathy resulted when a 17-month-old infant was intubated for 24 days and treated with vecuronium and high- dose methylprednisolone.(24) Sinus node exit block occurred in a 14-year-old after administration of 0.08 mg/kg.(25) Drug interactions: Concomitant administration of corticosteroids(26-28) and certain anti- biotics (e.g., aminoglycosides and polymyxin B)(29,30) with neuromuscular blockers has been shown to be a risk factor for prolonged paralysis. Reduce vecuronium dose to 0.04–0.06 mg/kg in patients receiving succinylcholine, enflu- rane, or isoflurane.(4) Concomitant use with atracurium in an equipotent dose is more potent than either agent alone.(31) Other: Disruption of the blood brain barrier in critical illness may cause penetration of vecuronium or atracurium into the CNS, resulting in dilated, nonreactive pupils. Three such cases were reported in a pediatric oncology unit.(32) For neonatal nonemergent intubations, AAP recommends that vagolytic and muscle relaxant agents should be considered, and that analgesic agents or anesthetic doses of a hypnotic agent should be administered. Rocuronium or vecuronium is preferred over other available neuromuscular blocking agents.(12)  865