Pancuronium Infusion for Neuromuscular Block in Children in the Pediatric Intensive Care Unit

Abstract

When neuromuscular blockade becomes necessary in the intensive care unit, there are several options available in regard to both the drug and the mode of delivery (continuous versus intermittent administration).Despite extensive experience with intermediate acting drugs such as atracurium or vecuronium, these muscle relaxants are costly and may account for a significant portion of the pharmacy charges. We undertook an open label study to evaluate the efficacy and dosing requirements for a less costly drug, pancuronium. The study group included 25 patients ranging in age from 3 mo to 17 yr and in weight from 3.2 to 68 kg. If the patient had not previously received neuromuscular blocking agents (NMBAs), pancuronium was administered as a bolus dose of 0.1 mg/kg followed by a continuous infusion of 0.05 mg centered dot kg-1 centered dot h-1. A nerve stimulator was applied to either the ulnar or peroneal nerve and a standard train-of-four (TOF) was monitored every 2 h. In patients that had previously received other NMBAs, no bolus dose of pancuronium was administered and the infusion was started at 0.05 mg centered dot kg-1 centered dot h-1. The pancuronium infusion was increased or decreased by increments of 0.01 mg centered dot kg-1 centered dot h-1 to maintain one to two twitches of the TOF. In patients that required an increase in the infusion rate, an additional bolus dose equivalent to the current hourly rate was administered and then followed by the increase in the infusion rate. Pancuronium infusion requirements varied from 0.03 to 0.22 mg centered dot kg-1 centered dot h-1 (mean = 0.07 +/- 0.03 mg centered dot kg-1 centered dot h-1). The infusion requirement was 0.05 to 0.08 mg centered dot kg-1 centered dot h-1 in 71 of 98 days (72.4%) and 0.03 to 0.09 mg centered dot kg-1 centered dot h-1 in 84 of the 98 days (85.7%). There was an increased infusion requirement in patients receiving anticonvulsants (0.056 vs 0.14 mg centered dot kg-1 centered dot h-1, P < 0.5) and in patients that required pancuronium for more than 5 days (0.059 on Day 1 vs 0.083 mg centered dot kg-1 centered dot h-1 on Day 5, P = 0.03). Pancuronium can be used by continuous infusion in children for neuromuscular block. Its use may be significantly less costly than newer NMBAs such as atracurium or vecuronium. (Anesth Analg 1995;81:13-6)