Adult Dosing

Endotracheal intubation

• Start dose: 0.08-0.1 mg/kg IV bolus. Skeletal muscle relaxation usually occurs in 2.5-3 minutes
• If initial dose of vecuronium is administered 5 minutes after the start of inhalation agent or when steady-state has been achieved, decrease the dose by ~15% (0.06-0.085 mg/kg)
• If intubation is performed using succinylcholine, reduce the initial dose to 0.04-0.06 mg/kg with inhalation anesthesia and 0.05-0.06 mg/kg with balanced anesthesia
• First maintenance dose of 0.01-0.015 mg/kg IV within 25-40 minutes after the initial injection, then q12-15 minutes under balanced anesthesia
• Alt: 0.15-0.28 mg/kg can be administered during surgery under halothane anesthesia

To maintain skeletal muscle relaxation during surgery or mechanical ventilation

• Start dose: 0.08-0.1 mg/kg IV bolus. Skeletal muscle relaxation usually occurs in 2.5-3 minutes
• Use by continuous infusion
• Initiate 1mcg/kg/min ~20-40 min after the initial intubating dose
• Average infusion rates range from 0.8-1.2 mcg/kg/min
• Infusion should be initiated only after early evidence of spontaneous recovery from the bolus dose

Pediatric Dosing

• Safety and effectiveness in pediatric patients <7 wks of age have not been established

Endotracheal intubation

• 7 wk-1yr
• Moderately more sensitive than adults and may require slightly lower doses and may take about 1.5x as long to recover

• 1-10 yrs
• May require a slightly higher initial dose and may also require supplementation slightly more often than adults

• 10-16 yrs
• Start dose: 0.08-0.1 mg/kg IV bolus. Skeletal muscle relaxation usually occurs in 2.5-3 minutes
• If initial dose of vecuronium is administered 5 minutes after the start of inhalation agent or when steady-state has been achieved, decrease the dose by ~15% (0.06-0.085 mg/kg)
• If intubation is performed using succinylcholine, reduce the initial dose to 0.04-0.06 mg/kg with inhalation anesthesia and 0.05-0.06 mg/kg with balanced anesthesia
• First maintenance dose of 0.01-0.015 mg/kg IV within 25-40 minutes after the initial injection, then q12-15 minutes under balanced anesthesia
• Alt: 0.15-0.28 mg/kg can be administered during surgery under halothane anesthesia

To maintain skeletal muscle relaxation during surgery or mechanical ventilation

• 7 wk-1yr
• Moderately more sensitive than adults and may require slightly lower doses and may take about 1.5x as long to recover

• 1-10 yrs
• May require a slightly higher start dose and may also require supplementation slightly more often than adults

• 10-16 yrs
• Start dose: 0.08-0.1 mg/kg IV bolus. Skeletal muscle relaxation usually occurs in 2.5-3 minutes
• Use by continuous infusion
• Initiate 1mcg/kg/min ~20-40 min after the initial intubating dose
• Average infusion rates range from 0.8-1.2 mcg/kg/min
• Infusion should be initiated only after early evidence of spontaneous recovery from the bolus dose

[Outline]

• Adult Dosing
• Pediatric Dosing

• Indicated as an adjunct to general anesthesia, to facilitate endotracheal intubation and to provide skeletal muscle relaxation during surgery or mechanical ventilation

• Hypersensitivity to any of the ingredients of the product
• Intramuscular administration

• The drug should be administered by adequately trained individuals familiar with its actions, characteristics, and hazards

Renal Dose Adjustment (Based on CrCl)

• Renal impairment: No dose adjustments; if anephric patients cannot be prepared for non-elective surgery, consider a lower initial dose

Hepatic Dose Adjustment

• Hepatic impairment: Dose adjustment not defined; caution advised

• Vecuronium should be administered in carefully adjusted dosage by or under the supervision of experienced clinicians who are well trained in its use and where facilities for intubation, artificial respiration, oxygen therapy, and reversal agents are immediately available
• Patients with myasthenia gravis or the myasthenic (Eaton-Lambert) syndrome should be carefully monitored while on treatment as even small doses may have profound effects in such patients
• Severe anaphylactic reactions, sometimes fatal or life-threatening reactions, have occurred with vecuronium
• A lower initial dose should be considered in anephric patients
• Caution should be exercised in individuals with previous anaphylactic reactions to other neuromuscular blocking agents because there have been reports of cross-reactivity between neuromuscular blocking agents
• Dosage should not be increased in patients with slower circulation time e.g., those with CV disease, old age and edematous states
• Prolonged use of neuromuscular blocking drugs to provide mechanical ventilation may cause prolonged paralysis and/or muscle weakness
• Long-term use in immobilized patients may lead to symptoms consistent with disuse muscle atrophy. Hence, when prolonged mechanical ventilation is being indicated, the benefits-to-risk ratio of neuromuscular blockade must be considered
• In the ICU, it is recommended to appropriately monitor neuromuscular transmission using a peripheral nerve stimulator during administration and recovery
• Additional doses of vecuronium should not be given before a definite response to T1 or to the first twitch is noted. Discontinue infusion until a response returns
• Patients with severe obesity or neuromuscular disease may exhibit airway and/or ventilatory problems requiring special attention before, during and after therapy
• Drugs used in anesthetic practice may trigger a potentially fatal hypermetabolism of skeletal muscle known as malignant hyperthermia

Cautions: Use cautiously in

• Hepatic disease
• Biliary obstruction
• History of neuromuscular disease
• Pulmonary disease
• Hepatic impairment
• Anticonvulsant use
• Endocrine disease
• Acid-base disorder
• Dehydration
• Electrolyte abnormalities
• Carcinomatosis
• Severe hypothermia
• Febrile patients
• Major trauma or burns
• Cerebral palsy
• Hemiparesis or paraparesis
• Cachetic or debilitated patients

Pregnancy Category:C

Breastfeeding: Unknown. Manufacturer advises caution.

• RESP: Apnea, bronchospasm, respiratory depression
• MUSC: Muscle weakness, prolonged skeletal muscle paralysis (long-term use)
• MISC: Anaphylactic reaction, hypersensitivity reactions

• Non-depolarizing neuromuscular blocking agent; binds competitively to cholinergic receptors at the motor end-plate to antagonize the action of acetylcholine resulting in neuromuscular blockade
• Metabolism: Hepatic; CYP450: Unknown
• Excretion: Urine (3-35%), bile (25-50%)
• Half-life
• Healthy surgical patients and in renal failure patients undergoing transplant surgery: 65-75 minutes
• In late pregnancy: 35-40 minutes

US Trade Name(s)

• Only generic available

US Availability

vecuronium (generic)

• PWD for INJ: 10 mg/vial
• PWD for INJ: 20 mg/vial

Canadian Trade Name(s)

• Only generic available

Canadian Availability

vecuronium (generic)

• PWD for INJ: 10 mg/vial
• PWD for INJ: 20 mg/vial

UK Trade Name(s)

• Norcuron

UK Availability

Norcuron

• PWD for INJ: 10 mg/vial

Australian Trade Name(s)

• Norcuron

Australian Availability

Norcuron

• PWD for INJ: 4 mg/amp
• PWD for INJ: 10 mg/vial

[Outline]

Anesthesia

Neuromuscular Blocking Agents