Production of skeletal muscle relaxation during surgery after general anesthesia has been induced.
Facilitation of endotracheal intubation; however, succinylcholine generally is preferred in emergency situations where rapid intubation is required. A single dose should not be used in place of succinylcholine for rapid sequence induction of anesthesia (“crash intubation”).
Treatment to increase pulmonary compliance during assisted or controlled respiration after general anesthesia has been induced.
Adjust dosage carefully according to individual requirements and response.
Assess neuromuscular blockade and recovery in patients undergoing anesthesia; a peripheral nerve stimulator is recommended to accurately monitor the degree of muscle relaxation and to minimize the possibility of overdosage.
To avoid patient distress, administer only after unconsciousness has been induced.
Facilitation of Endotracheal Intubation
Endotracheal intubation for nonemergency surgical procedures generally can be performed within 2.5–3 minutes following administration of 0.08- to 0.1-mg/kg dose. (See Onset and also Duration under Pharmacokinetics.)
Maintenance of Neuromuscular Blockade
Repeated administration of maintenance doses appears to have little, if any, cumulative effect on duration of neuromuscular blockade.
Rate of spontaneous recovery from neuromuscular blockade following discontinuance of maintenance infusion usually is comparable to that following administration of a single IV injection.
Close monitoring recommended to avoid excessive dosage when continuous infusion is employed.
For solution and drug compatibility information, see Compatibility under Stability.
Administer initial (intubating) dose by rapid IV injection; administer maintenance dosage for prolonged surgical procedures by intermittent IV injection or continuous IV infusion.
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
Reconsititute vial containing 10 or 20 mg of vercuronium bromide with 10 or 20 mL of bacteriostatic water for injection, respectively, to provide a solution containing 1 mg/mL. Use within 5 days.
When reconstituted with other compatible solutions (see Solution Compatibility under Stability), 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 (see Solution Compatibility under Stability). Use within 24 hours.
Dosage
Available as vecuronium bromide; dosage expressed in terms of the salt.
Pediatric Patients
Skeletal Muscle Relaxation
Initial (Intubating) Dosage
IV
Children 7 weeks to 1 year of age may receive dosages recommended for adults. (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 dosages recommended for adults. (See Adults under Dosage and Administration.)
Maintenance Dosage
Intermittent IV Injection
Children 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.
Adults
Skeletal Muscle Relaxation
Initial (Intubating) Dosage
IV
0.08–0.1 mg/kg. (See Onset and also Duration under Pharmacokinetics.)
Reduce initial dosage 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 Interactions: Specific Drugs.
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 dosage 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. Increase dose (i.e., to >0.01–0.015 mg/kg) if longer intervals between doses are desirable.
Administer first maintenance dose generally 25–45 minutes after the initial dose in patients undergoing balanced or inhalation anesthesia.
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).
Continuous IV Infusion
Initially, 1 mcg/kg per minute. Adjust infusion rate to maintian 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 rapid IV 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.
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., Clcr <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.)
Intensive Care Setting
Dosage recommendations not established for prolonged, continuous IV infusions during mechanical ventilation in intensive care settings. (See Intensive Care Setting under Cautions.)
Patients with Neuromuscular Disease
Administer small test dose (e.g., 0.005–0.02 mg/kg) and monitor response. (See Neuromuscular Disease 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 Histamine Release under Cautions.)
Cautions
Contraindications
Known hypersensitivity to vercuronium bromide or any ingredient in the formulation.
Warnings/Precautions
Warnings
Respiratory Effects
Potential for severely compromised respiratory function and respiratory paralysis.
Should be used only by individuals experienced in the use of neuromuscular blocking agents and in the maintenance of an adequate airway and respiratory support. Facilities and personnel necessary for intubation, administration of oxygen, and assisted or controlled respiration should be immediately available.
Administer small test dose; monitor response carefully with a peripheral nerve stimulator.
Sensitivity Reactions
Hypersensitivity Reactions
Histamine-like hypersensitivity reactions (e.g., bronchospasm, flushing, redness, hypotension, and tachycardia) are not likely to occur.
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.
Intensive Care Setting
Possible prolonged paralysis and/or muscle weakness and atrophy.
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.
Impaired Circulation
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.
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.
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 vercuronium 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.
Possible increased potency and prolonged duration of neuromuscular blockade
Administer vecuronium in reduced dosage after effects of succinylcholine begin to dissipate
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.
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
15–30°C; protect from light.
Following reconstitution with bacteriostatic water for injection containing benzyl alcohol, 2–8°C or room temperature (<30°C) for 5 days.
Following reconstitution with sterile water for injection or other compatible solution (see Solution Compatibility under Stability), 2–8°C for 24 hours.
Compatibility
For information on systemic interactions resulting from concomitant use, see Interactions.
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.)
Preparations
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Vecuronium Bromide
Routes
Dosage Forms
Strengths
Brand Names
Manufacturer
Parenteral
For injection, for IV use only
10 mg*
Vecuronium Bromide for Injection
Baxter, Bedford, Hospira, Sicor, Steris
20 mg*
Vecuronium Bromide for Injection
Baxter, Bedford, Hospira, Sicor, Steris
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name
Remember, keep this and all other medicines out of the reach of children,
never share your medicines with others, and use this medication only for the indication prescribed.
