Pancuronium is used as an adjunct to general anaesthesia to aid endotracheal intubation and to produce skeletal muscle relaxation during surgical procedures of moderate to prolonged duration.

Pancuronium is a non-depolarizing, curare-like neuromuscular blocking agent. It acts by competitively blocking acetylcholine at nicotinic receptors on the motor end plate of the neuromuscular junction. By displacing acetylcholine from these receptors, it prevents nerve impulses from being transmitted to muscles, resulting in muscle relaxation and paralysis. Unlike depolarizing agents such as suxamethonium, pancuronium does not cause initial muscle fasciculations because it does not produce depolarization of the muscle membrane.

Pancuronium has no hormonal effects. It shows mild vagolytic activity (reducing vagus nerve influence) but does not block autonomic ganglia. The neuromuscular blockade produced by pancuronium can be reversed by anticholinesterase agents, which increase the availability of acetylcholine at the neuromuscular junction.

Intravenous:

Facilitate endotracheal intubation, Muscle relaxant in general anaesthesia:

• Adult: Initially, 50–100 mcg/kg by inj, may reduce to 20–60 mcg/kg if given after suxamethonium. Maintenance: 10–20 mcg/kg.
• Child: 0–30 days Initially, 30–40 mcg/kg. Maintenance: 10–20 mcg/kg; >1 mth Same as adult dose.

Facilitate mechanical ventilation in intensive care:

• Adult: 60 mcg/kg every 1–1.5 hr or less frequently.

The effects may be increased when used with inhalational anaesthetics, other non-depolarising muscle relaxants, certain antibiotics (polypeptide and aminoglycoside groups), diazepam, propranolol, high doses of thiamine, MAO inhibitors, quinidine, magnesium sulfate, protamine, nitroglycerin, narcotic analgesics, diuretics, phenytoin, alpha and beta adrenergic blockers, imidazoles, norepinephrine, epinephrine, and prior administration of suxamethonium. The effects may be reduced when used with neostigmine, edrophonium, high-dose corticosteroids, potassium chloride (KCl), calcium chloride (CaCl₂), sodium chloride (NaCl), heparin (temporary effect), azathioprine, theophylline, pyridostigmine, neuroleptanalgesia, and propanidid.

Pancuronium is contraindicated in patients with known hypersensitivity to pancuronium or bromide ions.

Reported side effects include tachycardia, hypertension, bradycardia, bronchospasm, hypotension, cardiovascular collapse, and excessive salivation. Pain or local skin reactions may occur at the injection site. Hypersensitivity reactions are rare.

Pregnancy Category C. Animal studies have shown potential risks to the fetus, and there are no adequate human studies. The drug should be used during pregnancy only if the expected benefit outweighs the potential risk.

Use with caution in patients with burns, biliary tract disease, pulmonary disease, muscular dystrophy, myasthenia gravis, myasthenic syndrome, electrolyte imbalance, altered pH, dehydration, cardiovascular disease, edema, elevated catecholamine levels, and hypertension risk. Caution is also required in patients with renal or hepatic impairment, children, and during pregnancy and lactation.

Obese patients: Dose adjustment should be based on ideal body weight.

Renal impairment:

• Hemodialysis/peritoneal dialysis: avoid use
• Continuous renal replacement therapy: use 50% of normal dose
• Creatinine clearance <10 mL/min: avoid use
• Creatinine clearance 10–50 mL/min: use 50% of normal dose

Symptoms include prolonged apnea, respiratory depression, and muscle weakness, which may lead to respiratory failure and death. Management includes administration of neostigmine (2.5 mg) and atropine (1.2 mg) to reverse neuromuscular blockade, along with continued ventilatory support. If reversal is unsuccessful, assisted ventilation should be maintained until spontaneous breathing returns.

Non-depolarizing muscle relaxant