Pancuronium bromide

How it works

It competitively antagonises acetylcholine at nicotinic receptors of the neuromuscular junction, preventing depolarisation of the motor end-plate and producing flaccid paralysis until the block is reversed or spontaneously recovers.

Prescribing in practice

• It produces paralysis without any sedative or analgesic effect, so adequate concurrent sedation and analgesia must always be ensured before and throughout its use to prevent awareness during paralysis.
• Its long duration and vagolytic action commonly cause tachycardia and hypertension, making it less suitable where these are undesirable, and its effect is prolonged in renal impairment because of renal elimination.
• Neuromuscular function should be monitored, and residual block reversed with an anticholinesterase plus antimuscarinic once recovery has begun.

Monitoring

Monitor the depth of block with a peripheral nerve stimulator alongside heart rate and blood pressure.

Counselling the patient

• This drug temporarily paralyses the muscles to allow surgery and ventilation and is always given with drugs that keep the patient asleep and pain-free.
• Breathing is fully supported by a ventilator while it is working.
• Its effects last longer than many newer relaxants, particularly if the kidneys are not working well.

Evidence & guidelines

Pancuronium is a long-established long-acting neuromuscular blocker; contemporary practice favours intermediate-acting agents, but the principle of ensuring sedation during neuromuscular blockade is a fundamental safety standard.