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VECURONIUM BROMIDE (vecuronium bromide for injection) Dosage and Administration

DOSAGE AND ADMINISTRATION

Vecuronium bromide for injection is for intravenous use only.

This drug should be administered by or under the supervision of experienced clinicians familiar with the use of neuromuscular blocking agents. Dosage must be individualized in each case. The dosage information which follows is derived from studies based upon units of drug per unit of body weight and is intended to serve as a guide only, especially regarding enhancement of neuromuscular blockade of vecuronium by volatile anesthetics and by prior use of succinylcholine (see PRECAUTIONS, Drug Interactions). Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit.

To obtain maximum clinical benefits of vecuronium and to minimize the possibility of overdosage, the monitoring of muscle twitch response to peripheral nerve stimulation is advised.

The recommended initial dose of vecuronium bromide is 0.08 to 0.1 mg/kg (1.4 to 1.75 times the ED90) given as an intravenous bolus injection. This dose can be expected to produce good or excellent non-emergency intubation conditions in 2.5 to 3 minutes after injection. Under balanced anesthesia, clinically required neuromuscular blockade lasts approximately 25-30 minutes, with recovery to 25% of control achieved approximately 25 to 40 minutes after injection and recovery to 95% of control achieved approximately 45-65 minutes after injection. In the presence of potent inhalation anesthetics, the neuromuscular blocking effect of vecuronium is enhanced. If vecuronium is first administered more than 5 minutes after the start of inhalation agent or when steady-state has been achieved, the initial vecuronium bromide dose may be reduced by approximately 15%, i.e., 0.06 to 0.085 mg/kg.

Prior administration of succinylcholine may enhance the neuromuscular blocking effect and duration of action of vecuronium. If intubation is performed using succinylcholine, a reduction of initial dose of vecuronium bromide to 0.04 to 0.06 mg/kg with inhalation anesthesia and 0.05 to 0.06 mg/kg with balanced anesthesia may be required.

During prolonged surgical procedures, maintenance doses of 0.01 to 0.015 mg/kg of vecuronium bromide are recommended; after the initial vecuronium bromide injection, the first maintenance dose will generally be required within 25 to 40 minutes. However, clinical criteria should be used to determine the need for maintenance doses.

Since vecuronium lacks clinically important cumulative effects, subsequent maintenance doses, if required, may be administered at relatively regular intervals for each patient, ranging approximately from 12 to 15 minutes under balanced anesthesia, slightly longer under inhalation agents. (If less frequent administration is desired, higher maintenance doses may be administered.)

Should there be reason for the selection of larger doses in individual patients, initial doses ranging from 0.15 mg/kg up to 0.28 mg/kg have been administered during surgery under halothane anesthesia without ill effects to the cardiovascular system being noted as long as ventilation is properly maintained (see CLINICAL PHARMACOLOGY).

Use by Continuous Infusion

After an intubating dose of 80 to 100 mcg/kg, a continuous infusion of 1 mcg/kg/min can be initiated approximately 20-40 min later. Infusion of vecuronium should be initiated only after early evidence of spontaneous recovery from the bolus dose. Long-term intravenous infusion to support mechanical ventilation in the intensive care unit has not been studied sufficiently to support dosage recommendations (see PRECAUTIONS).

The infusion of vecuronium should be individualized for each patient. The rate of administration should be adjusted according to the patient’s twitch response as determined by peripheral nerve stimulation. An initial rate of 1 mcg/kg/min is recommended, with the rate of the infusion adjusted thereafter to maintain a 90% suppression of twitch response. Average infusion rates may range from 0.8 to 1.2 mcg/kg/min.

Inhalation anesthetics, particularly enflurane and isoflurane may enhance the neuromuscular blocking action of nondepolarizing muscle relaxants. In the presence of steady-state concentrations of enflurane or isoflurane, it may be necessary to reduce the rate of infusion 25-60 percent, 45‑60 min after the intubating dose. Under halothane anesthesia it may not be necessary to reduce the rate of infusion.

Spontaneous recovery and reversal of neuromuscular blockade following discontinuation of vecuronium infusion may be expected to proceed at rates comparable to that following a single bolus dose (see CLINICAL PHARMACOLOGY).

Infusion solutions of vecuronium can be prepared by mixing vecuronium with an appropriate infusion solution such as Dextrose Injection 5%, Sodium Chloride Injection 0.9%, Dextrose (5%) and Sodium Chloride Injection, or Lactated Ringer’s Injection.

Unused portions of infusion solutions should be discarded.

Infusion rates of vecuronium bromide can be individualized for each patient using the following table:

Drug Delivery Rate
(mcg/kg/min)

Infusion Delivery Rate
(mL/kg/min)

0.1 mg/mL*

0.2 mg/mL

0.7

0.007

0.0035

0.8

0.008

0.004

0.9

0.009

0.0045

1

0.01

0.005

1.1

0.011

0.0055

1.2

0.012

0.006

1.3

0.013

0.0065

*  10 mg of vecuronium bromide in 100 mL solution
   20 mg of vecuronium bromide in 100 mL solution

The following table is guideline for mL/min delivery for a solution of 0.1 mg/mL (10 mg in 100 mL) with an infusion pump.

Vecuronium Bromide Infusion Rate – mL/min

Amount of Drug
mcg/kg/min

Patient Weight – kg

40

50

60

70

80

90

100

0.7

0.28

0.35

0.42

0.49

0.56

0.63

0.7

0.8

0.32

0.4

0.48

0.56

0.64

0.72

0.8

0.9

0.36

0.45

0.54

0.63

0.72

0.81

0.9

1

0.4

0.5

0.6

0.7

0.8

0.9

1

1.1

0.44

0.55

0.66

0.77

0.88

0.99

1.1

1.2

0.48

0.6

0.72

0.84

0.96

1.08

1.2

1.3

0.52

0.65

0.78

0.91

1.04

1.17

1.3

NOTE: If a concentration of 0.2 mg/mL is used (20 mg in 100 mL), the rate should be decreased by one-half.

USE in Pediatric Patients

Older pediatric patients (10 to 16 years of age) have approximately the same dosage requirements (mg/kg) as adults and may be managed the same way. Younger pediatric patients (1 to 10 years of age) may require a slightly higher initial dose and may also require supplementation slightly more often than adults.

Infants under one year of age but older than 7 weeks are moderately more sensitive to vecuronium on a mg/kg basis than adults and take about 1½ times as long to recover. See also subsection of PRECAUTIONS titled Pediatric Use. Information presently available does not permit recommendation on usage in pediatric patients less than 7 weeks of age (see PRECAUTIONS). There are insufficient data concerning continuous infusion of vecuronium in pediatric patients, therefore, no dosing recommendations can be made.

Compatibility

Vecuronium bromide is compatible in solution with:

Sodium Chloride Injection 0.9%

Dextrose Injection 5%

Sterile Water for Injection

Dextrose (5%) and Sodium Chloride 0.9% Injection

Lactated Ringer’s Injection

Use within 24 hours of mixing with the above solutions.

Vecuronium bromide is also compatible in solution with:

Bacteriostatic Water for Injection (NOT FOR USE IN NEWBORNS). Use within 5 days of mixing with the above solution.

Reconstituted vecuronium bromide, which has an acid pH, should not be mixed with alkaline solutions (e.g., barbiturate solutions such as thiopental) in the same syringe or administered simultaneously during intravenous infusion through the same needle or through the same intravenous line.

After Reconstitution

See DOSAGE AND ADMINISTRATION – Compatibility: for diluents compatible with Vecuronium Bromide for Injection.

  • When reconstituted with bacteriostatic water for injection: CONTAINS BENZYL ALCOHOL, WHICH IS NOT INTENDED FOR USE IN NEWBORNS. Use within 5 days. May be stored at room temperature or refrigerated.
  • When reconstituted with sterile water for injection or other compatible I.V. solutions not containing an antimicrobial preservative (e.g., sterile water for injection): Refrigerate vial. Use within 24 hours. Single use only. Discard unused portion.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration whenever solution and container permit.

Risk of Medication Errors

Accidental administration of neuromuscular blocking agents may be fatal. Store vecuronium bromide with the cap and ferrule intact and in a manner that minimizes the possibility of selecting the wrong product.

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