Download NEUROMUSCULAR BLOCKING AGENTS

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1
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High Alert
NEUROMUSCULAR BLOCKING AGENTS
(nondepolarizing)
Plate # 0-Composite
pg 1 # 1
Pharmacokinetics
Absorption: Following IV administration, absorption is essentially complete.
Distribution: Atracurium— Distributes into extracellular space; crosses the placenta. Cisatracurium— Rapidly distributes into extracellular space. Pancuronium— Rapidly distributes into extracellular fluid; small amounts cross the placenta. Rocuronium— Rapidly distributes into extracellular space. Vecuronium—
Rapidly distributes in extracellular fluid; minimal penetration of the CNS.
Metabolism and Excretion: Atracurium— Metabolized in plasma; ⬍5% excreted unchanged in urine. Cisatracurium— Undergoes pH-dependent breakdown, which is responsible for 80% of metabolism; remainder eliminated by liver
and kidneys. Pancuronium— Excreted mostly unchanged by the kidneys; small
amounts are eliminated in bile. Rocuronium— Mostly metabolized and eliminated
by the liver. Vecuronium— Some metabolism by the liver (20%), with conversion to
at least one active metabolite; 35% excreted unchanged by the kidneys.
Half-life: Atracurium— Infants: 20 min; Children: 17 min; Adults: 16 min; Cisatracurium— 22– 31 min; Pancuronium— 2 hr; Rocuronium— Infants 3– 12
mo: 0.8– 1.8 hr; Children 1– 3 yr: 0.4– 1.8 hr; Children 3– 8 yr: 0.5– 1.1 hr; Adults:
1.4– 2.4 hr (qto 4.3 hr in hepatic impairment and 2.4 hr in renal impairment); Vecuronium— Infants: 65 min; Children: 41 min; Adults: 65– 75 min (pnear term in
pregnant patients,qin hepatic impairment).
TIME/ACTION PROFILE (neuromuscular blockade)
atracurium
(a-tra-kyoor-ee-um)
Tracrium
cisatracurium
(siss-a-tra-kyoor-ee-um)
Nimbex
pancuronium
(pan-cure-oh-nee-yum)
Pavulon
rocuronium
(roe-kyoor-own-ee-um)
Zemuron
vecuronium
(ve-cure-oh-nee-yum)
Norcuron
Classification
Therapeutic: neuromuscular blocking agents-nondepolarizing
Pregnancy Category B (cisatracurium only), C
ROUTE
ONSET
PEAK
DURATION
Atracurium IV
Cisatracurium IV
Pancuronium IV
Rocuronium IV
1–4 min
2–3min
30–45 sec
1 min
Indications
Vecuronium IV
1–3 min
3–5 min
3–5 min
2–3 min
0.5–1 min (peds) 1–
3.7 min (adults)
3–5 min
20–35 min
28–50 min
40–60 min
26–40 min (peds) 31
min (adults)*
30–40 min
Induction of skeletal muscle paralysis and facilitation of intubation after induction of
anesthesia in surgical procedures. Facilitation of compliance during mechanical ventilation.
*Following 0.6 mg/kg dose in adult patients.
Action
nium, vecuronium only); Pedi: Products containing benzyl alcohol should be
avoided in neonates.
Use Cautiously in: Underlying cardiovascular disease (qrisk of arrhythmias; less
with atracurium or vecuronium); Dehydration or electrolyte abnormalities (should
Prevent neuromuscular transmission by blocking the effect of acetylcholine at the
myoneural junction. Have no analgesic or anxiolytic properties. Therapeutic Effects: Skeletal muscle paralysis.
⫽ Canadian drug name.
⫽ Genetic Implication.
Contraindications/Precautions
Contraindicated in: Hypersensitivity; Hypersensitivity to bromides (pancuro-
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
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be corrected); Situations in which histamine release would be problematic (worse
with atracurium; less with cisatracurium and vecuronium); Fractures or muscle
spasm; Hyperthermia (qduration/intensity of paralysis); Significant hepatic impairment (pmetabolism of vecuronium, altered response to others); Shock; Extensive
burns (may be more resistant to effects of cisatracurium); Low plasma pseudocholinesterase levels (may be seen in association with anemia, dehydration, cholinesterase inhibitors/insecticides, severe liver disease, pregnancy, or hereditary predisposition); Obese patients; Geri: Geriatric patients or patients with impaired renal
function (slower onset to complete paralysis with cisatracurium;pelimination of
pancuronium); OB, Lactation, Pedi: Safety not established for some agents; most
agents have been used safely in pregnant women undergoing cesarean section; selected agents have been used safely in children.
Exercise Extreme Caution in: Neuromuscular diseases such as myasthenia
gravis (small test dose may be used to assess response).
Adverse Reactions/Side Effects
Resp: bronchospasm. CV: atracurium— hypotensionpancuronium, hypertensionatracurium, pancuronium, tachycardia. GI: pancuronium— excessive salivation. Derm: rash atracurium, skin flushing. Misc: allergic reactions including
ANAPHYLAXIS.
Interactions
Drug-Drug: Intensity and duration of paralysis may be prolonged by pretreatment
with succinylcholine, general anesthesia (inhalation), aminoglycosides, vancomycin, tetracyclines, polymyxin B, colistin, clindamycin, lidocaine, and
other local anesthetics, lithium, quinidine, procainamide, beta-adrenergic
blocking agents, potassium-losing diuretics, or magnesium. Higher infusion
rates may be required and duration of action may be shortened in patients receiving
long-term carbamazepine or phenytoin. Rocuronium associated with QTc interval prolongation when administered with general anesthesia.
Route/Dosage
Atracurium
IV (Adults and Children ⬎2 yr): 0.4– 0.5 mg/kg initially (0.25– 0.35 mg/kg if administered after steady-state anesthesia with enflurane or isoflurane or 0.3– 0.4 mg/
Plate # 0-Composite
pg 2 # 2
kg following succinylcholine); may then repeat with 0.08– 0.1 mg/kg 20– 45 min after initial dose as needed, or by continuous infusion at 5– 9 mcg/kg/min.
IV (Neonates , Infants, and Children 1 mo– 2 yr): 0.3– 0.4 mg/kg initially followed by maintenance doses of 0.3– 0.4 mg/kg as needed.
Cisatracurium
IV (Adults and Children ⬎12 yr): Initial intubating dose— 0.15– 0.2 mg/kg,
additional maintenance doses of 0.03 mg/kg may be used 40– 65 min later; Continuous infusion— 1– 3 mcg/kg/min.
IV (Children 2– 12 yr): Initial intubating dose— 0.1– 0.15 mg/kg; Continuous
infusion— 1– 3 mcg/kg/min.
IV (Infants 1– 23 mo): Initial intubating dose— 0.15 mg/kg.
Pancuronium
IV (Adults and Children ⬎1 mo): Initial intubating dose— 0.06– 0.1 mg/kg
initially; additional doses of 0.01 mg/kg may be given q 25– 60 min to maintain paralysis. Continuous infusion— 1– 2 mcg/kg/min.
Rocuronium
IV (Adults): Rapid sequence tracheal intubation— 0.6– 1.2 mg/kg; Maintenance dosing— 0.1– 0.2 mg/kg, repeat doses as needed; Continuous infusion—
10– 12 mcg/kg/min (range 4– 16 mcg/kg/min).
IV (Children ⱖ3 mo): Intubation dose— 0.6 mg/kg; Maintenance dose—
0.075– 0.125 mg/kg; Continuous infusion— 12 mcg/kg/min.
Vecuronium
IV (Adults and Children ⬎10 yr): Intubation— 0.08– 0.1 mg/kg (0.06– 0.085
mg/kg if given after steady-state anesthesia achieved or 0.04– 0.06 mg/kg after succinylcholine-assisted intubation and anesthesia; wait for disappearance of succinylcholine effects; or 0.05– 0.06 mg/kg during balanced anesthesia); Maintenance
dose— 0.01– 0.015 mg/kg 25– 40 min after initial dose, then q 12– 15 min as
needed; Continuous infusion— 0.8– 1.2 mcg/kg/min.
IV (Children 1– 10 yr): 0.1 mg/kg q 1 hr as needed.
IV (Infants 7 wk– 1 yr): 0.1 mg/kg q 1 hr as needed or as a continuous infusion of
1– 1.5 mcg/kg/min.
NURSING IMPLICATIONS
Assessment
● Assess respiratory status continuously throughout therapy with neuromuscular
blocking agents. These medications should be used only to facilitate intubation or
in patients already intubated.
䉷 2015 F.A. Davis Company
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CONTINUED
NEUROMUSCULAR BLOCKING AGENTS
(nondepolarizing)
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●
● Neuromuscular response should be monitored with a peripheral nerve stimulator
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intraoperatively. Paralysis is initially selective and usually occurs sequentially in
the following muscles: levator muscles of eyelids, muscles of mastication, limb
muscles, abdominal muscles, muscles of the glottis, intercostal muscles, and the
diaphragm. Recovery of muscle function usually occurs in reverse order.
Monitor ECG, heart rate, and BP throughout administration.
Observe the patient for residual muscle weakness and respiratory distress during
the recovery period.
Monitor infusion site frequently. If signs of tissue irritation or extravasation occur,
discontinue and restart in another vein.
Toxicity and Overdose: If overdose occurs, use peripheral nerve stimulator to
determine the degree of neuromuscular blockade. Maintain airway patency and
ventilation until recovery of normal respirations occurs.
Administration of anticholinesterase agents (neostigmine, pyridostigmine) may
be used to antagonize the action of neuromuscular blocking agents once the patient has demonstrated some spontaneous recovery from neuromuscular block.
Atropine is usually administered prior to or concurrently with anticholinesterase
agents to counteract the muscarinic effects.
Administration of fluids and vasopressors may be necessary to treat severe hypotension or shock.
Potential Nursing Diagnoses
Ineffective breathing pattern (Indications)
Impaired verbal communication (Side Effects)
Fear (Side Effects)
Implementation
● High Alert: Unplanned administration of a neuromuscular blocking agent in-
stead of administration of the intended medication or administration of a neuromuscular blocking agent in the absence of ventilatory support has resulted in seri⫽ Canadian drug name.
⫽ Genetic Implication.
●
●
●
Plate # 0-Composite
pg 3 # 3
ous harm and death. Confusing similarities in packaging and insufficiently
controlled access to these medications are often implicated in these medication
errors.
Dose is titrated to patient response.
Neuromuscular blocking agents have no effect on consciousness or pain threshold. Adequate anesthesia/analgesia should always be used when neuromuscular
blocking agents are used as an adjunct to surgical procedures or when painful
procedures are performed. Benzodiazepines and/or analgesics should be administered concurrently when prolonged neuromuscular blocker therapy is used for
ventilator patients, because patient is awake and able to feel all sensations.
If eyes remain open throughout prolonged administration, protect corneas with
artificial tears.
Store atracurium, cisatracurium, pancuronium, rocuronium, and vecuronium in
refrigerator. To prevent absorption by plastic, pancuronium should not be stored
in plastic syringes. May be administered in plastic syringes.
Most neuromuscular blocking agents are incompatible with barbiturates and sodium bicarbonate. Do not admix.
IV Administration
Atracurium
● Direct IV: May be administered undiluted. Rate: Administer initial IV dose as a
bolus over 1 min.
● Intermittent Infusion: Maintenance dose is usually required 20– 45 min fol-
lowing initial dose.
● Diluent: D5W, 0.9% NaCl, or D5/0.9% NaCl. Administer every 15– 25 min or by
continuous infusion.
● Continuous Infusion: Maintenance dose is administered by infusion. Concen-
tration: 0.5 mg/ml for continuous infusion. Rate: Titrate according to patient
response.
● Y-Site Compatibility: acyclovir, alemtuzumab, alfentanil, amikacin, aminocaproic acid, amiodarone, amphotericin B lipid, anidulafungin, argatroban, ascorbic acid, atropine, azathioprine, aztreonam, benztropine, bivalirudin, bleomycin,
bumetanide, buprenorphine, butorphanol, caclium chloride, calcium gluconate,
carboplatin, carmustine, caspofungin, cefazolin, cefotaxime, cefoxitin, ceftriaxone, cefuroxime, chloramphenicol, chlorpromazine, cisplatin, clindamycin, cyanocobalamin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, dapto-
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
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mycin, dexamethasone, dexmedetomidine, dexrazoxane, digoxin, diltiazem,
diphenhydramine, dobutamine, docetaxel, dopamine, doxycycline, enalaprilat,
ephedrine, epinephrine, epirubicin, epoetin alfa, eptifibatide, ertapenem, erythromycin, esmolol, etomidate, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, fluconazole, fludarabine, fluorouracil, folic acid, foscarnet,
gemcitabine, gentamicin, glycopyrrolate, granisetron, hydrocortisone sodium
succinate, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin, irinotecan, isoproterenol, ketorolac, labetalol, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, metaraminol,
methcillin, methotrexate, methyldopate, methylprednisolone, metoclopramide,
metoprolol, metronidazole, midazolam, milrinone, mitoxantrone, morphine,
moxifloxacin, multivitamins, mycophenolate, nafcillin, nalbuphine, naloxone, nesiritide, nicardipine, nitroglycerin, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, papaverine,
pemetrexed, penicillin G, pentamidine, pentazocine, phentolamine, phenylephrine, phytonadione, potassium acetate, potassium chloride, procainamide, prochlorperazine, promethazine, propranolol, protamine, pyridoxime, quinapristin/
dalfopristin, ranitidine, sodium acetate, streptokinase, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiamine, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, tolazoline, vancomycin, vasopressin, verapamil, vinblastine, vincristine, vinorelbine, zolendronic acid.
● Y-Site Incompatibility: aminophylline, amphotericin B colloidal, cefoperazone, ceftazidime, dantrolene, diazepam, diazoxide, furosemide, ganciclovir, indomethacin, pantoprazole, pentobarbital, phenobarbitol, phenytoin, sodium bicarbonate, thiopental.
Cisatracurium
● Direct IV: May be administered undiluted. Rate: Administer over 5– 10 sec.
● Intermittent Infusion: Diluent: D5W, 0.9% NaCl, or D5/0.9% NaCl. Solution is
stable for 24 hr at room temperature or if refrigerated. Concentration: 0.1– 0.4
mg/ml. Rate: Administer at an initial rate of 3 mcg/kg/min, then decrease to 1– 2
mcg/kg/min.
● Y-Site Compatibility: alemtuzumab, alfentanil, amikacin, aminocaproic acid,
amiodarone, amphotericin B lipid complex, anidulafungin, argatroban, arsenic
trioxide, azithromycin, aztreonam, bivalirudin, bleomycin, bumetanide, bupren-
Plate # 0-Composite
pg 4 # 4
orphine, butorphanol, calcium gluconate, carboplatin, carmustine, caspofungin,
ceftaroline, ceftriaxone, chlorpromazine, ciprofloxacin, cisplatin, clindamycin,
cyclophosphamide, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmedetomidine, dexrazoxane, digoxin, diltiazem, diphenhydramine, dobutamine,
docetaxel, dopamine, doxorubicin liposomal, doxycycline, droperidol, enalaprilat, epinephrine, epirubicin, eptifibatide, ertapenem, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, fluconazole, fludarabine, fluorouracil, foscarnet, gemcitabine, gentamicin, granisetron, haloperidol,
hydrocortisone, hydromorphone, hydroxyzine, idarubicin, ifosfamide, imipenem-cilastatin, irinotecan, isoproterenol, ketorolac, leucovorin calcium, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, methotrexate, metoclopramide, metronidazole, midazolam,
milrinone, mitoxantrone, morphine, moxifloxacin, mycophenolate, nalbuphine,
nesiritide, nicardipine, nitroglycerin, norepinephrine, octreotide, ondansetron,
oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pemetrexed, phenylephrine, potassium acetate, potassium chloride, procainamide, prochlorperazine, promethazine, quinupristin/dalfopristin, ranitidine, remifentanil, sodium
acetate, sufentanil, tacrolimus, teniposide, theophylline, thiotepa, tigecycline, tirofiban, tobramycin, vancomycin, vasorpessin, vinblastine, vincristine, vinorelbine, voriconazole, zidovudine, zolendronic acid.
● Y-Site Incompatibility: amphotericin B cholesteryl , cefoperazone, micafungin,
pantoprazole.
Pancuronium
● Direct IV: May be administered undiluted.
● Intermittent Infusion: Diluent: 0.9% NaCl, D5W, D5/0.9% NaCl, and LR injec-
tion. Solution is stable for 48 hr. Concentration: 0.01– 0.8 mg/ml. Rate: Titrate rate according to patient response.
● Syringe Compatibility: heparin.
● Y-Site Compatibility: acyclovir, alemtuzumab, alfentanil, amifostine, amikacin,
aminocaproic acid, aminophylline, amphotericin B liposome, ampicillin, ampicillin/sulbactam, anidulafungin, argatroban, azithromycin, aztreonam, bivalirudin,
bleomycin, bumetanide, buprenorphine, busulfan, butorphanol, calcium chloride, calcium gluconate, carboplatin, carmustine, cefazolin, cefepime, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, chlorpromazine, ciprofloxacin, cisplatin, clindamycin, cyclophosphamide,
cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone, dexmede䉷 2015 F.A. Davis Company
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CONTINUED
NEUROMUSCULAR BLOCKING AGENTS
(nondepolarizing)
tomidine, dexrazoxane, diltiazem, diphenhydramine, dobutamine, docetaxel, dolasetron, dopamine, doxorubicin, doxorubicin liposomal, doxycycline, droperidol, enalaprilat, ephedrine, epinephrine, epirubicin, eptifibatide, ertapenem,
erythromycin, esmolol, etomidate, etoposide, etoposide phosphate, famotidine,
fenoldopam, fentanyl, fluconazole, fludarabine, fluorouracil, foscarnet, ganciclovir, gemcitabine, gentamicin, glycopyrrolate, granisetron, haloperidol, heparin,
hydralazine, hydrocortisone sodium succinate, hydromorphone, idarubicin, ifosfamide, imipenem-cilastatin, insulin, irinotecan, isoproterenol, ketamine, ketorolac, labetalol, leucovorin calcium, levofloxacin, lidocaine, linezolid, lorazepam,
magnesium sulfate, mannitol, mechlorethamine, melphalan, meperidine, meropenem, methohexital, methotrexate, methyldopate, methylprednisolone, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, mitoxantrone,
morphine, moxifloxacin, mycophenolate, nafcillin, nalbuphine, naloxone, nesiritide, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxaliplatin, paclitaxel, palonosetron, pamidronate, pemetrexed, pentamidine, pentazocine, pentobarbital, phenobarbital, phenylephrine, piperacillin/tazobactam,
potassium acetate, potassium chloride, potassium phosphates, procainamide,
prochlorperazine, promethazine, propranolol, quinupristin/dalfopristin, ranitidine, remifentanil, sodium acetate, sodium bicarbonate, sodium phosphates,
streptozocin, sufentanil, tacrolimus, teniposide, theophylline, thiotepa, ticarcillin/
clavulanate, tigecycline, tirofiban, tobramycin, trimethoprim/sulfamethoxazole,
vancomycin, verapamil, vinblastine, vincristine, vinorelbine, voriconazole, zidovudine, zolendronic acid.
● Y-Site Incompatibility: allopurinol, amphotericin B colloidal, caspofungin,
dantrolene, diazepam, furosemide, pantoprazole, phenytoin, thiopental.
Rocuronium
● Direct IV: Administer undiluted. Rate: Titrate according to patient response.
● Continuous Infusion: Diluent: 0.9% NaCl, sterile water for injection, D5W, LR
injection, and D5/0.9% NaCl for infusion. Solution is stable for 24 hr at room tem⫽ Canadian drug name.
⫽ Genetic Implication.
Plate # 0-Composite
pg 5 # 5
perature. Concentration: 0.5– 1 mg/mL. Rate: Infusion rates of 0.004– 0.016
mg/kg/min have been used. Rate of infusion should be titrated according to patient’s twitch response as monitored with a peripheral nerve stimulator.
● Y-Site Compatibility: acyclovir, alemtuzumab, alfentanil, amikacin, aminocaproic acid, aminophylline, amiodarone, ampicillin, ampicillin/sulbactam, anidulafungin, argatroban, azithromycin, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate,
carboplatin, carmustine, caspofungin, cefepime, cefotaxime, cefotetan, cefoxitin,
ceftazidime, ceftriaxone, cefuroxime, chlorpromazine, ciprofloxacin, clindamycin, cyclophosphamide, cytarabine, daptomycin, dexmedetomidine, dexrazoxane, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel, dolasetron,
dopamine, doxycycline, droperidol, enalaprilat, ephedrine, epinephrine, epirubicin, eptifibatide, ertapenem, esmolol, etoposide, etoposide phosphate, fenoldopam, fentanyl, fluconazole, fludarabine, foscarnet, fosphenytoin, ganciclovir,
gemcitabine, gentamicin, granisetron, haloperidol, heparin, hydrocortisone sodium phosphate, hydromorphone, idarubicin, ifosfamide, imipenem/cilastatin,
irinotecan, isoproterenol, labetalol, levofloxacin, levorphanol, lidocaine, linezolid, magnesium hydroxide, mannitol, mechlorethamine, meperidine, meropenem, methotrexate, metoclopramide, metoprolol, metronidazole, midazolam,
milrinone, mitoxantrone, morphine, moxifloxacin, mycophenolate, nalbuphine,
naloxone, nesiritide, nicardipine, nitroglycerin, nitroprusside, octreotide, ondansetron, oxaliplatin, palonosetron, pamidronate, pemetrexed, pentamidine, pentobarbital, phenobarbital, phenylephrine, potassium acetate, potassium chloride,
procainamide, prochlorperazine, promethazine, propranolol, quinupristin/dalfopristin, ranitidine, remifentanil, sodium acetate, sodium bicarbonate, sodium
phosphates, sufentanil, tacrolimus, teniposide, theophylline, thiotepa, ticarcillin/
clavulanate, tigecycline, tirofiban, tobramycin, vasopressin, verapamil, vincristine, voriconazole, zidovudine, zolendronic acid.
● Y-Site Incompatibility: amphotericin B colloidal, amphotericin B lipid complex, azathioprine, cefoperazone, diazepam, furosemide, hydrocortisone sodium
succinate, insulin, ketorolac, lorazepam, methohexital, methoprednisolone, micafungin, pantoprazole, phenytoin, piperacillin/tazobactam, potassium phosphates, thiopental.
Vecuronium
● IV: Reconstitute vecuronium with bacteriostatic water (may be provided by manu-
facturer), D5W, 0.9% NaCl, D5/0.9% NaCl, or LR injection. Solution reconstituted
CAPITALS indicate life-threatening, underlines indicate most frequent.
Strikethrough ⫽ Discontinued.
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with bacteriostatic water is stable if refrigerated for 5 days. If other diluents are
used, solution is stable for 24 hr if refrigerated. Discard all unused solution.
● Direct IV: Concentration: Maximum of 2 mg/ml. Titrate dose according to patient response.
● Continuous Infusion: Dilute vecuronium to a concentration of 1 mg/ml in D5W,
0.9% NaCl, or LR. Use sterile water for injection instead of manufacturer-provided
diluent (contains benzyl alcohol) when reconstituting for use in neonates. Rate:
Titrate rate of infusion according to patient response.
● Y-Site Compatibility: alemtuzumab, alfentanil, alprostadil, amifostine, amikacin, aminophylline, amiodarone, ampicillin, ampicillin/sulbactam, anidulafungin,
argatroban, azithromycin, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, carboplatin,
carmustine, caspofungin, cefazolin, cefotetan, cefoxitin, ceftazidime, ceftriaxone,
cefuroxime, chlorpromazine, ciprofloxacin, cisplatin, clindamycin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone
sodium phosphate, dexmedetomidine, dexrazoxane, digoxin, diltiazem, diphenhydramine, dobutamine, docetaxel, dolasetron, dopamine, doxorubicin hydrochloride, doxorubicin liposomal, doxycycline, droperidol, enalaprilat, ephedrine,
epinephrine, epirubicin, eptifibatide, ertapenem, erythromycin, esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, fluconazole, fludarabine, fluorouracil, foscarnet, gemcitabine, gentamicin, glycopyrrolate, granisetron, haloperidol, heparin, hydralazine, hydrocortisone sodium succinate,
hydromorphone, idarubicin, ifosfamide, insulin, irinotecan, isoproterenol, labetalol, leucovorin calcium, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlorethamide, melphalan, meperidine, meropenem,
methotrexate, methyldopate, metoclopramide, metoprolol, metronidazole, midazolam, milrinone, mitoxantrone, morphine, moxifloxacin, mycophenolate, nalbuphine, naloxone, nesiritide, nicardipine, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxaliplatin, paclitaxel, palonosetron,
pamidronate, pemetrexed, pentazocine, pentobarbital, phenobarbital, phenylephrine, potassium acetate, potassium chloride, potassium phosphates, procainamide, prochlorperazine, promethazine, propranolol, quinupristin/dalfopristin,
ranitidine, remifentanil, sodium acetate, sodium bicarbonate, sodium phosphates, streptozocin, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiotepa, ticarcillin/clavulanate, tigecycline, tirofiban, tobramycin, trimeth-
Plate # 0-Composite
pg 6 # 6
oprim/sulfamethoxazole, vancomycin, vasopressin, verapamil, vinblastine,
vincristine, vinorelbine, voriconazole, zidovudine, zolendronic acid.
● Y-Site Incompatibility: acyclovir, allopurinol, amphotericin B cholesteryl , amphotericin B colloidal, amphotericin B lipid complex, amphotericin B liposome,
busulfan, cefepime, cefotaxime, chloramphenicol, dantrolene, diazepam, etomidate, furosemide, ganciclovir, ibuprofen, imipenem/cilastatin, ketorolac, methohexital, methylprednisolone sodium succinate, micafungin, nafcillin, pantoprazole, pentamidine, phenytoin, piperacillin/tazobactam, thiopental.
Patient/Family Teaching
● Explain all procedures to patient receiving neuromuscular blocker therapy with-
out general anesthesia, because consciousness is not affected by neuromuscular
blocking agents alone.
● Reassure patient that communication abilities will return as the medication wears
off.
Evaluation/Desired Outcomes
● Adequate suppression of the twitch response when tested with peripheral nerve
stimulation and subsequent muscle paralysis.
● Improved compliance during mechanical ventilation.
● Diagnosis of myasthenia gravis.
Why was this drug prescribed for your patient?
䉷 2015 F.A. Davis Company
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