Drug class: Neuromuscular Blocking Agents

Medically reviewed by Drugs.com on Sep 10, 2024. Written by ASHP.

Introduction

Nondepolarizing neuromuscular blocking agent; aminosteroid.

Uses for Vecuronium Bromide

Skeletal Muscle Relaxation

Production of skeletal muscle relaxation during surgery after general anesthesia has been induced.

Facilitation of endotracheal intubation; however, a neuromuscular blocking agent with a rapid onset of action (e.g., succinylcholine, rocuronium) generally preferred in emergency situations when rapid intubation is required.

Has been used to facilitate mechanical ventilation in the ICU; however, manufacturer states insufficient data available to support dosage recommendations for such use. Whenever neuromuscular blocking agents are used in the ICU, consider benefits versus risks of such therapy and assess patients frequently to determine need for continued paralysis. (See Intensive Care Setting under Cautions.)

Compared with other neuromuscular blocking agents, vecuronium has an intermediate onset and duration of action, and exhibits minimal cardiovascular effects. Not suitable for rapid sequence intubation, but may be used for procedures requiring profound muscle relaxation for short durations (e.g., laryngoscopy, bronchoscopy) or for maintenance of neuromuscular blockade during the postintubation period.

Vecuronium Bromide Dosage and Administration

General

Dispensing and Administration Precautions

• Facilities and personnel necessary for intubation, administration of oxygen, and respiratory support should be immediately available. (See Boxed Warning.)

• Take special precautions (e.g., segregate storage, limit access, affix warning labels to storage containers and final administration containers) to ensure that the drug is not administered without adequate respiratory support. Institute for Safe Medication Practices (ISMP) recommends the following wording on auxiliary labels: “Warning: Paralyzing agent—causes respiratory arrest—patient must be ventilated.”

• Assess neuromuscular blockade and recovery with a peripheral nerve stimulator to accurately monitor the degree of muscle relaxation, determine need for additional doses, and minimize possibility of overdosage. (See Administration Precautions under Cautions.)

• To avoid patient distress, administer in conjunction with adequate analgesia and sedation, and only after unconsciousness has been induced.

• A reversal agent should be readily available in the event of a failed intubation or to accelerate neuromuscular recovery after surgery. (See Reversal of Neuromuscular Blockade under Dosage and Administration.)

Reversal of Neuromuscular Blockade

• To reverse neuromuscular blockade, administer a cholinesterase inhibitor (e.g., neostigmine, pyridostigmine, edrophonium) in conjunction with an anticholinergic agent such as atropine or glycopyrrolate to block adverse muscarinic effects of the cholinesterase inhibitor. Alternatively, may use sugammadex to reverse the effects of vecuronium after surgery.

• To minimize risk of residual neuromuscular blockade, attempt reversal only after some degree of spontaneous recovery has occurred; monitor patients closely until adequate recovery of normal neuromuscular function is assured (i.e., ability to maintain satisfactory ventilation and a patent airway).

Administration

Administer IV only; do not administer IM.

IV Administration

Administer initial (intubating) dose by rapid IV injection; administer maintenance doses by intermittent IV injection or continuous IV infusion.

Use of a controlled-infusion device is recommended during continuous IV infusion.

Rate of spontaneous recovery following discontinuance of a maintenance infusion usually is comparable to that following administration of a single IV injection.

Repeated administration of maintenance doses appears to have little, if any, cumulative effect on duration of neuromuscular blockade.

Consult specialized references for specific procedures and techniques of administration.

Do not mix in the same syringe or administer through the same needle as an alkaline solution.

Reconstitution

Reconstitute vecuronium bromide for injection with a compatible IV solution (e.g., 5% dextrose, 5% dextrose and 0.9% sodium chloride, 0.9% sodium chloride, lactated Ringer's, bacteriostatic water for injection).

When reconstituted with bacteriostatic water for injection, use within 5 days; when reconstituted with other compatible solutions, use within 24 hours and discard unused portions.

Dilution

For continuous IV infusion, dilute the reconstituted solution to the desired concentration (usually 0.1 or 0.2 mg/mL) in a compatible IV solution . Vecuronium is unstable in the presence of bases.

Standardize 4 Safety

Standardized concentrations for vecuronium have been established through Standardize 4 Safety (S4S), a national patient safety initiative to reduce medication errors, especially during transitions of care. Because recommendations from the S4S panels may differ from the manufacturer’s prescribing information, caution is advised when using concentrations that differ from labeling, particularly when using rate information from the label. For additional information on S4S (including updates that may be available), see [Web].

Paralytics are recommended to be administered as straight drug. This provides consistency between operating room and the ICU, and eliminates potential compounding errors.

dosing units differ from concentration units

Babies under 500 g may require a lower concentration.

Dosage

Available as vecuronium bromide; dosage expressed in terms of the salt.

Adjust dosage carefully according to individual requirements and response.

Pediatric Patients

Skeletal Muscle Relaxation

Initial (Intubating) Dose

IV

Infants >7 weeks but <1 year of age may receive doses comparable to those used in adults, but may experience a longer period of time (about 1.5 times) to neuromuscular recovery. (See Adults under Dosage and Administration.)

Children 1–9 years of age may require slightly higher initial doses than adults. (See Adults under Dosage and Administration.)

Children >10 years of age should receive doses recommended for adults. (See Adults under Dosage and Administration.)

Maintenance Dosage

Intermittent IV Injection

Infants 7 weeks to 1 year of age may receive doses recommended for adults; however, less frequent administration may be necessary. (See Adults under Dosage and Administration and also see Pediatric Use under Cautions.)

Children 1–9 years of age may require more frequent doses than adults. (See Adults under Dosage and Administration.)

Children >10 years of age should receive dosages recommended for adults. (See Adults under Dosage and Administration.)

Continuous IV Infusion

Dosage recommendations not established; administration by continuous IV infusion not adequately studied in pediatric patients.

Adults

Skeletal Muscle Relaxation

Initial (Intubating) Dose

IV

0.08–0.1 mg/kg. Following administration of this initial dose, endotracheal intubation for nonemergency surgical procedures can be performed within 2.5–3 minutes in most patients. (See Onset and also Duration under Pharmacokinetics.)

Reduce initial dose by about 15% (i.e., to 0.06–0.085 mg/kg) when administered >5 minutes after administration of enflurane, isoflurane, or halothane has been initiated or after steady-state anesthesia has been achieved. (See Specific Drugs under Interactions.)

If larger initial dose is required, 0.15–0.28 mg/kg has been administered in patients undergoing halothane anesthesia with minimal adverse cardiovascular effects as long as ventilation was adequately maintained.

If administering following succinylcholine, reduce dose to 0.05–0.06 mg/kg with balanced anesthesia or 0.04–0.06 mg/kg with inhalation anesthesia.

Maintenance Dosage

Intermittent IV Injection

0.01–0.015 mg/kg, administered as necessary, in patients receiving balanced anesthesia.

0.008–0.012 mg/kg, administered as necessary, in patients receiving inhalation anesthesia.

First maintenance dose generally required 25–45 minutes after the initial dose in patients undergoing balanced or inhalation anesthesia.

May administer repeat maintenance doses at relatively regular intervals (i.e., from 12–15 minutes in patients undergoing balanced anesthesia or at slightly longer intervals in those undergoing enflurane or isoflurane anesthesia).

May increase dose (i.e., to >0.01–0.015 mg/kg) if longer intervals between maintenance doses are desirable.

Continuous IV Infusion

After initial intubating dose is administered, may initiate continuous IV infusion to maintain neuromuscular blockade during prolonged procedures.

Individualize infusion rates based on patient response to peripheral nerve stimulation.

Manufacturer recommends initial rate of 1 mcg/kg per minute. Subsequently adjust infusion rate to maintain 90% neuromuscular blockade; 0.8–1.2 mcg/kg per minute usually maintains continuous neuromuscular blockade in most patients.

Initiate continuous IV infusion only after early spontaneous recovery from initial IV dose is evident (approximately 20–40 minutes after administration of initial dose ). Required infusion rates decrease progressively and become relatively constant within 30–50 minutes.

May need to reduce infusion rate by about 25–60% approximately 45–60 minutes following initial IV dose if steady-state anesthesia has been induced with enflurane or isoflurane. Reduction in infusion rate may not be necessary if steady-state anesthesia has been induced with halothane.

Manufacturer states use of continuous IV infusion during mechanical ventilation in the ICU has not been adequately studied to date to establish dosage recommendations.

Special Populations

Hepatic Impairment

Data currently insufficient for specific dosage recommendations. Some clinicians suggest usual initial dose; others suggest a reduced initial dose. Adjust maintenance dosing (probably with reduced doses) carefully according to patient’s response. (See Hepatic Impairment under Cautions.)

Renal Impairment

Usual initial and maintenance doses recommended for patients with renal failure who are optimally prepared with dialysis prior to surgery; monitor carefully to determine interval between doses. (See Renal Impairment under Cautions.)

Manufacturer recommends consideration of decreased initial dose if emergency surgery is necessary in patients with severe renal failure (i.e., Cl_cr <10 mL/minute) who are not optimally prepared with dialysis; however, most clinicians believe that usual initial dose may be given. Adjust maintenance doses carefully according to patient’s response.

Geriatric Patients

Dosage necessary to maintain steady-state neuromuscular blockade may be decreased.

Burn Patients

Substantially increased doses may be required due to development of resistance. (See Burn Patients under Cautions.)

Patients with Neuromuscular Disease

Administer small test dose (e.g., 0.005–0.02 mg/kg) and monitor response. (See Neuromuscular Diseases under Cautions.)

Other Populations

Patients in whom substantial histamine release would be particularly hazardous (e.g., patients with clinically important cardiovascular disease) or patients with any history suggesting a greater risk of histamine release (e.g., a history of severe anaphylactoid reactions or asthma): Administer slowly over 1–2 minutes or longer; discontinue administration if any signs of histamine release occur. (See Hypersensitivity Reactions under Cautions.)

Cautions for Vecuronium Bromide

Contraindications

• Known hypersensitivity to vecuronium bromide.

Warnings/Precautions

Warnings

Administration Precautions

Because of the potential for severely compromised respiratory function and other complications, take special precautions during administration. (See Boxed Warning and also see General under Dosage and Administration.)

Neuromuscular Diseases

Possible exaggerated neuromuscular blockade in patients with neuromuscular diseases (e.g., myasthenia gravis, Eaton-Lambert syndrome).

Administer small test dose; monitor response carefully with a peripheral nerve stimulator.

Sensitivity Reactions

Hypersensitivity Reactions

Serious hypersensitivity reactions, including anaphylaxis, reported rarely. Potential for cross-sensitivity with other neuromuscular blocking agents (both depolarizing and nondepolarizing).

Take appropriate precautions; emergency treatment for anaphylaxis should be immediately available.

General Precautions

Burn Patients

Resistance to therapy can develop in burn patients, particularly those with burns over 25–30% or more of body surface area.

Resistance becomes apparent ≥1 week after the burn, peaks ≥2 weeks after the burn, persists for several months or longer, and decreases gradually with healing.

Consider possible need for substantially increased doses.

Cardiovascular Effects

Exhibits minimal cardiovascular effects; therefore, will not counteract the bradycardia induced by many anesthesia agents (e.g., high-dose fentanyl) or by vagal stimulation.

Possible delayed onset of action and delayed maximum effect in patients with impaired circulation or in those with cardiovascular disease or edema (vecuronium volume of distribution may be increased). Larger-than-usual initial doses are not recommended; caution advised when administering a subsequent dose before the maximum effect of the initial dose is attained.

Intensive Care Setting

Possible prolonged paralysis and/or muscle weakness and atrophy with long-term administration of neuromuscular blocking agents in the ICU.

Continuous monitoring of neuromuscular transmission recommended during neuromuscular blocking agent therapy in intensive care setting. Do not administer additional doses before there is a definite response to nerve stimulation tests. If no response is elicited, discontinue administration until response returns.

Electrolyte Disturbances

Possible prolonged paralysis in patients with electrolyte disturbances (e.g., increased plasma magnesium concentrations) or acid-base imbalances.

Carefully monitor the degree of neuromuscular blockade with a peripheral nerve stimulator in patients with severe electrolyte disturbances (i.e., hypermagnesemia, hypokalemia, hypocalcemia) or diseases that result in electrolyte disturbances (e.g., adrenocortical insufficiency).

Malignant Hyperthermia

Malignant hyperthermia is rarely associated with use of neuromuscular blocking agents and/or potent inhalation anesthetics. Insufficient data to determine whether vecuronium is capable of initiating the development of this condition.

Be vigilant for possible development of malignant hyperthermia and prepared for its management in any patient undergoing general anesthesia.

Carcinomatosis

Carefully monitor the degree of neuromuscular blockade with a peripheral nerve stimulator.

Obesity

Use with caution in severely obese patients; maintenance of adequate airway and ventilation support prior to, during, and following administration of neuromuscular blocking agents may require particular care.

Debilitated Patients

Carefully monitor the degree of neuromuscular blockade with a peripheral nerve stimulator in patients with severe debilitation.

Specific Populations

Pregnancy

Category C.

Lactation

Not known whether vecuronium is distributed into milk. Caution advised if used in nursing women.

Pediatric Use

Safety and efficacy not established in children <7 weeks of age.

Has been used safely and effectively in children >7 weeks of age who were undergoing surgery. Children 7 weeks–1 year of age may be more sensitive than adults to the neuromuscular blocking effects and generally require 50% longer to recover from neuromuscular blockade.

Vecuronium bromide that has been reconstituted with bacteriostatic water for injection containing benzyl alcohol should not be used in neonates.

Geriatric Use

Possible increased time to onset of neuromuscular blockade and decreased rate of recovery compared with younger adults.

Hepatic Impairment

Prolonged duration of and rate of recovery from neuromuscular blockade.

Use with caution; careful monitoring with a peripheral nerve stimulator recommended.

Renal Impairment

Onset and duration of and rate of recovery from neuromuscular blockade not substantially altered by renal dysfunction; however, possible prolonged duration of blockade in patients with severe renal impairment who have not undergone dialysis prior to surgery. Careful monitoring with a peripheral nerve stimulator recommended to avoid inadvertent overdosage; consider reduced initial dose.

Common Adverse Effects

Skeletal muscle weakness.

Drug Interactions

Specific Drugs

Vecuronium Bromide Pharmacokinetics

Absorption

Bioavailability

Poorly absorbed from the GI tract.

Onset

Time to maximum neuromuscular blockade decreases as the dose increases.

Following IV administration of 0.08–0.1 mg/kg, neuromuscular blockade begins within 1 minute and is maximal at 3–5 minutes.

Duration

Duration of neuromuscular blockade increases as the dose increases.

Duration of clinically sufficient neuromuscular blockade induced by initial dose of 0.08–0.1 mg/kg under balanced or halothane anesthesia is about 25–30 or 30–40 minutes, respectively.

Spontaneous recovery to about 25% of baseline generally occurs within 25–40 minutes under balanced anesthesia and is usually 95% complete 45–65 minutes after administration.

The time necessary for 25–75% recovery from neuromuscular blockade following doses of 0.08–0.1 mg/kg under balanced or halothane anesthesia is about 15–25 minutes; recovery time following initial doses appears to be dose dependent.

Special Populations

Hepatic dysfunction (i.e., cirrhosis, cholestasis) may prolong duration of and rate of recovery from neuromuscular blockade.

In patients with severe renal impairment who have not undergone dialysis prior to surgery, duration of neuromuscular blockade may be prolonged.

In geriatric patients, increased time of onset and decreased rate of recovery from neuromuscular blockade.

In patients undergoing cardiopulmonary bypass surgery under induced hypothermia, duration of neuromuscular blockade may be prolonged.

Distribution

Extent

Appears to rapidly distribute into extracellular space. Undergoes rapid and extensive hepatic extraction. Crosses the placenta minimally; not known whether distributed into milk.

Plasma Protein Binding

Approximately 60–90%.

Special Populations

In children <1 year of age, volume of distribution is increased. In geriatric patients, volume of distribution may be decreased. In patients with renal failure, volume of distribution may be slightly increased.

Elimination

Metabolism

Metabolic fate not fully characterized in humans. In vitro, vecuronium undergoes spontaneous deacetylation to form hydroxy derivatives.

Elimination Route

Excreted principally in feces via biliary elimination; also excreted in urine.

Half-life

Biphasic; terminal elimination half-life averages 65–75 minutes.

Special Populations

In patients with cirrhosis, half-life averages 84 minutes.

In patients with renal failure, half-life not substantially altered; potential for high plasma concentrations of 3-desacetyl vecuronium (neuromuscular blocking activity is ≥50% of that of vecuronium).

During late pregnancy, half-life decreases to about 35–40 minutes.

Stability

Storage

Parenteral

Powder for Injection

20–25°C; protect from light.

Following reconstitution with bacteriostatic water for injection, store at room temperature or under refrigeration; use within 5 days.

Following reconstitution with sterile water for injection or other compatible solution , store under refrigeration and use within 24 hours.

Actions

• Produces skeletal muscle relaxation by causing a decreased response to acetylcholine (ACh) at the myoneural (neuromuscular) junction of skeletal muscle.

• Exhibits high affinity for ACh receptor sites and competitively blocks access of ACh to motor end-plate of myoneural junction; may affect ACh release.

• Blocks the effects of both the small quantities of ACh that maintain muscle tone and the large quantities of ACh that produce voluntary skeletal muscle contraction; does not alter the resting electrical potential of the motor end-plate or cause muscular contractions.

• Exhibits minimal cardiovascular effects.

• Appears to have little histamine-releasing activity. A less potent stimulator of histamine release than atracurium or pancuronium.

Advice to Patients

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.

• Importance of informing clinician of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses (e.g., cardiovascular disease, neuromuscular disease).

• Importance of informing patients of other important precautionary information. (See Cautions.)

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer’s labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Reload page with references included

Medical Disclaimer