High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error.
Pronunciation: ve-cure-oh-nee-yum
Trade Name(s)
Norcuron
Ther. Class.
neuromuscular blocking agents-nondepolarizing
Indications
Induction of skeletal muscle paralysis and facilitation of intubation after induction of anesthesia in surgical procedures.
Facilitation of compliance during mechanical ventilation.
Action
Prevents neuromuscular transmission by blocking the effect of acetylcholine at the myoneural junction. Has no analgesic or anxiolytic properties
Therapeutic Effect(s):
Skeletal muscle paralysis.
Pharmacokinetics
Absorption: Following IV administration, absorption is essentially complete.
Distribution: Rapidly distributes in extracellular fluid; minimal penetration of the CNS.
Metabolism and Excretion: Some metabolism by the liver (20%), with conversion to at least one active metabolite; 35% excreted unchanged by the kidneys
Half-life: Infants: 65 min; Children: 41 min; Adults: 65–75 min (↓ near term in pregnant patients, ↑ in hepatic impairment).
TIME/ACTION PROFILE
ROUTE
ONSET
PEAK
DURATION
IV
1–3 min
3–5 min
30–40 min
Contraindication/Precautions
Contraindicated in:
Hypersensitivity
Hypersensitivity to bromides
Use Cautiously in:
Dehydration or electrolyte abnormalities (should be corrected)
Fractures or muscle spasm
Hyperthermia (↑ duration/intensity of paralysis)
Significant hepatic impairment
Shock
Extensive burns (may be more resistant to effects)
Low plasma pseudocholinesterase levels (may be seen in association with anemia, dehydration, cholinesterase inhibitors/insecticides, severe liver disease, pregnancy, or hereditary predisposition)
Obese patients
OB: Lactation: Safety not established (use only if benefit outweighs potential risk to fetus)
Pedi: Children <7 wk (safety and effectiveness not established)
Exercise Extreme Caution in:
Neuromuscular diseases such as myasthenia gravis (small test dose may be used to assess response).
Adverse Reactions/Side Effects
Resp: bronchospasm
Derm: rash
Misc: allergic reactions including ANAPHYLAXIS
* CAPITALS indicate life-threatening. Underline indicate most frequent.
Interactions
Drug-Drug
Intensity and duration of paralysis may be prolonged by pretreatment with succinylcholine, general anesthesia (inhalation), aminoglycosides, vancomycin, tetracyclines, polymyxin B, colistin, clindamycin, lidocaine, and other local anesthetics, lithium, quinidine, procainamide, beta-adrenergic blocking agents, potassium-losing diuretics, or magnesium.
Higher infusion rates may be required and duration of action may be shortened in patients receiving long-term carbamazepine or phenytoin.
Route/Dosage
IV (Adults and Children >10 yr): Intubation– 0.08–0.1 mg/kg (0.06–0.085 mg/kg if given after steady-state anesthesia achieved or 0.04–0.06 mg/kg after succinylcholine-assisted intubation and anesthesia; wait for disappearance of succinylcholine effects; or 0.05–0.06 mg/kg during balanced anesthesia); Maintenance dose– 0.01–0.015 mg/kg 25–40 min after initial dose, then q 12–15 min as needed; Continuous infusion– 0.8–1.2 mcg/kg/min.
IV (Children 1–10 yr): 0.1 mg/kg q 1 hr as needed.
IV (Infants 7 wk– 1 yr): 0.1 mg/kg q 1 hr as needed or as a continuous infusion of 1–1.5 mcg/kg/min.
Availability (generic available)
Powder for injection: 10 mg/vial, 20 mg/vial
Assessment
Assess respiratory status continuously throughout therapy with vecuronium. Should be used only to facilitate intubation or in patients already intubated.
Neuromuscular response should be monitored with a peripheral nerve stimulator intraoperatively. Paralysis is initially selective and usually occurs sequentially in the following muscles: levator muscles of eyelids, muscles of mastication, limb muscles, abdominal muscles, muscles of the glottis, intercostal muscles, and the diaphragm. Recovery of muscle function usually occurs in reverse order.
Monitor ECG, heart rate, and BP throughout administration.
Observe for residual muscle weakness and respiratory distress during the recovery period.
Monitor infusion site frequently. If signs of tissue irritation or extravasation occur, discontinue and restart in another vein.
Toxicity and Overdose:
If overdose occurs, use peripheral nerve stimulator to determine the degree of neuromuscular blockade. Maintain airway patency and ventilation until recovery of normal respirations occurs.
Administration of anticholinesterase agents (neostigmine, pyridostigmine) may be used to antagonize the action of neuromuscular blocking agents once the patient has demonstrated some spontaneous recovery from neuromuscular block. Atropine is usually administered prior to or concurrently with anticholinesterase agents to counteract the muscarinic effects.
Administration of fluids and vasopressors may be necessary to treat severe hypotension or shock.
High Alert: Unplanned administration of a neuromuscular blocking agent instead of administration of the intended medication or administration of a neuromuscular blocking agent in the absence of ventilatory support has resulted in serious harm and death. Confusing similarities in packaging and insufficiently controlled access to these medications are often implicated in these medication errors.
Dose is titrated to patient response.
Vecuronium has no effect on consciousness or pain threshold. Adequate anesthesia/analgesia should always be used when vecuronium is used as an adjunct to surgical procedures or when painful procedures are performed. Benzodiazepines and/or analgesics should be administered concurrently when prolonged vecuronium therapy is used for ventilator patients, because patient is awake and able to feel all sensations.
If eyes remain open throughout prolonged administration, protect corneas with artificial tears.
Store in refrigerator.
Most neuromuscular blocking agents are incompatible with barbiturates and sodium bicarbonate. Do not admix.
IV Administration
IV Reconstitute with bacteriostatic water (may be provided by manufacturer), D5W, 0.9% NaCl, D5/0.9% NaCl, or LR injection. Solution reconstituted with bacteriostatic water is stable if refrigerated for 5 days. If other diluents are used, solution is stable for 24 hr if refrigerated. Discard all unused solution.
IV Push: Concentration: Maximum of 2 mg/mL. Titrate dose according to patient response.
Continuous Infusion: Dilution: Dilute to a concentration of 1 mg/mL in D5W, 0.9% NaCl, or LR. Use sterile water for injection instead of manufacturer-provided diluent (contains benzyl alcohol) when reconstituting for use in neonates.
Rate: Titrate rate of infusion according to patient response.
Y-Site Compatibility:
alemtuzumab
alfentanil
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alprostadil
amifostine
amikacin
aminophylline
amiodarone
ampicillin
ampicillin/sulbactam
anidulafungin
argatroban
azithromycin
aztreonam
bivalirudin
bleomycin
bumetanide
buprenorphine
butorphanol
calcium chloride
calcium gluconate
carboplatin
carmustine
caspofungin
cefazolin
cefotetan
cefoxitin
ceftazidime
ceftriaxone
cefuroxime
chlorpromazine
ciprofloxacin
cisplatin
clindamycin
cyclophosphamide
cyclosporine
cytarabine
dactinomycin
daptomycin
dexamethasone sodium phosphate
dexmedetomidine
dexrazoxane
digoxin
diltiazem
diphenhydramine
dobutamine
docetaxel
dolasetron
dopamine
doxorubicin hydrochloride
doxorubicin liposomal
doxycycline
droperidol
enalaprilat
ephedrine
epinephrine
epirubicin
eptifibatide
ertapenem
erythromycin
esmolol
etoposide
etoposide phosphate
famotidine
fenoldopam
fentanyl
fluconazole
fludarabine
fluorouracil
foscarnet
gemcitabine
gentamicin
glycopyrrolate
granisetron
haloperidol
heparin
hydralazine
hydrocortisone sodium succinate
hydromorphone
idarubicin
ifosfamide
insulin
irinotecan
isoproterenol
labetalol
leucovorin calcium
levofloxacin
lidocaine
linezolid
lorazepam
magnesium sulfate
mannitol
melphalan
meperidine
meropenem
methotrexate
methyldopate
metoclopramide
metoprolol
metronidazole
midazolam
milrinone
mitoxantrone
morphine
moxifloxacin
mycophenolate
nalbuphine
naloxone
nicardipine
nitroglycerin
nitroprusside
norepinephrine
octreotide
ondansetron
oxaliplatin
paclitaxel
palonosetron
pamidronate
pemetrexed
pentobarbital
phenobarbital
phenylephrine
potassium acetate
potassium chloride
potassium phosphates
procainamide
prochlorperazine
promethazine
propranolol
quinupristin/dalfopristin
ranitidine
remifentanil
sodium acetate
sodium bicarbonate
sodium phosphates
streptozocin
succinylcholine
sufentanil
tacrolimus
teniposide
theophylline
thiotepa
tigecycline
tirofiban
tobramycin
trimethoprim/sulfamethoxazole
vancomycin
vasopressin
verapamil
vinblastine
vincristine
vinorelbine
voriconazole
zidovudine
zoledronic acid
Y-Site Incompatibility:
acyclovir
allopurinol
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amphotericin B cholesteryl
amphotericin B deoxycholate
amphotericin B lipid complex
amphotericin B liposome
busulfan
cefepime
cefotaxime
chloramphenicol
dantrolene
diazepam
etomidate
furosemide
ganciclovir
ibuprofen
imipenem/cilastatin
ketorolac
methohexital
methylprednisolone sodium succinate
micafungin
nafcillin
pantoprazole
pentamidine
phenytoin
piperacillin/tazobactam
thiopental
Patient/Family Teaching
Explain all procedures to patient receiving vecuronium therapy without general anesthesia, because consciousness is not affected by vecuronium alone.
Reassure patient that communication abilities will return as medication wears off.
Evaluation/Desired Outcomes
Adequate suppression of the twitch response when tested with peripheral nerve stimulation and subsequent muscle paralysis.
Improved compliance during mechanical ventilation.
vecuronium is a sample topic from the Davis's Drug Guide.
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