Pancuronium

How it works

It acts as a competitive antagonist at nicotinic acetylcholine receptors of the neuromuscular junction, preventing acetylcholine from triggering muscle depolarisation and contraction.

Prescribing in practice

• Administer only where facilities for immediate intubation, mechanical ventilation and oxygenation are available, as it produces complete respiratory paralysis with no sedative or analgesic effect.
• Its long duration and vagolytic action can cause tachycardia and hypertension, so it is generally avoided where these are undesirable and largely superseded by intermediate-acting agents.
• Effect is prolonged in renal impairment owing to dependence on renal elimination, and residual block can be reversed with an anticholinesterase plus an antimuscarinic.

Monitoring

Depth of block should be monitored with a peripheral nerve stimulator (train-of-four), alongside ventilation and haemodynamic parameters.

Counselling the patient

• Ensure adequate concurrent sedation and analgesia, as this drug paralyses but does not sedate or relieve pain.
• Confirm full recovery of neuromuscular function before extubation to avoid residual weakness.

Evidence & guidelines

Use is guided by the SPC and established anaesthetic practice, with newer intermediate-acting relaxants now preferred for most indications.