Paralysis in the Intensive Care Unit (ICU)

• Need for Sedation to Facilitate Mechanical Ventilation in Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome)

Procedural/Operative Paralysis

• xxx

Rapid Sequence Intubation (RSI) (see Airway Management)

• xxx

Aminosteroid Neuromuscular Junction Antagonist (see Neuromuscular Junction Antagonists)

• Blocks Acetylcholine Binding to Motor Endplate Receptors, Inhibiting Depolarization
  • Absence of Vagolytic Effect
  • Absence of Histamine Release

Metabolism

• Primarily Fecal: 40-75%
  • Renal Elimination as Unchanged Drug or Metabolites: 30%
  • Rate of Elimination is Significantly Decreased with Liver Disease, But Not with Renal Disease

Half-Life

• Elimination Half-Life
  • Healthy Patients (and Patients Undergoing Renal Transplant): 65-75 min
  • Late Pregnancy: 35-40 min

Dosing and Monitoring

Intravenous (IV) Push to Provide Paralysis for Rapid Sequence Intubation (see Airway Management)

• Dose: 0.08-0.1 mg/kg IVP (Usual Dose: 10 mg)
• Onset: 2.5-3.0 min (Maximal Effect Achieved within 3-5 min)
• Duration of Action: 25-40 min (95% Recovery within 45-60 min)

Intravenous (IV) Use for Paralysis in a Mechanically-Ventilated Patient in the Intensive Care Unit Setting

• Load (IV Push): 0.08-0.1 mg/kg
• Maintenance (IV Continuous Infusion): 0.8-1.7 μg/kg/min

Monitoring

• Using Train of Four

Dose Adjustment

• Hepatic: none specified in manufacturer labeling (however, dose reduction may be required)
• Renal: none specified in manufacturer labeling
  • Patients with Renal Insufficiency Do Not Generally Exhibit a Clinically Significant Prolonged Duration of Paralysis
  • However, Anephric Patients May Exhibit a Prolonged Duration of Paralysis
• Elderly: effects and duration of vecuronium are more variable in the elderly -> caution is advised
• Obesity (>130% of Ideal Body Weight): use ideal body weight to determine the dose
  • When Using Ideal Body Weight for Dosing, the Onset May Be Slightly Delayed

Use in Pregnancy (see Pregnancy)

• Category C: risk cannot be ruled out

Cautions

• Use of Vecuronium in the Setting of Possible Seizures
  • Vecuronium May Mask Seizure Activity (see Seizures)

Disease States Which Antagonize the Effects of Vecuronium

• Acid-Base Disturbance
  • Respiratory Alkalosis (see Respiratory Alkalosis)
• Burn Injury ≥20% Total Body Surface Area (see Burns): effect usually occurs several days after the burn injury and may persist for months after wound healing
• Electrolyte Disturbance
  • Hypercalcemia (see Hypercalcemia): decreases the effect of neuromuscular junction antagonists
• Immobilization
• Neuromuscular Disease
  • Demyelinating Disease: decreases the effect of neuromuscular junction antagonists
  • Denervation: decreases the effect of neuromuscular junction antagonists
  • Muscle Trauma: decreases the effect of neuromuscular junction antagonists
  • Peripheral Neuropathy (see Peripheral Neuropathy): decreases the effect of neuromuscular junction antagonists

Disease States Which Enhance the Effects of Vecuronium

• Acid-Base Distubance
  • Metabolic Acidosis (see Metabolic Acidosis-Normal Anion Gap and Metabolic Acidosis-Elevated Anion Gap)
  • Metabolic Alkalosis (see Metabolic Alkalosis)
  • Respiratory Acidosis (see Respiratory Acidosis)
• Electrolyte Disturbances
  • Hypermagnesemia (see Hypermagnesemia)
  • Hypocalcemia (Severe) (see Hypocalcemia)
  • Hypokalemia (Severe) (see Hypokalemia)
• Hypothermia see Hypothermia): increases the duration of action of vecuronium
• Neuromuscular Disease
  • Lambert-Eaton Myasthenic Syndrome (LEMS) (see Lambert-Eaton Myasthenic Syndrome)
  • Myasthenia Gravis (see Myasthenia Gravis)

Drug Interactions

• Acetylcholinesterase Inhbitors: acetylcholinesterase inhibitors antagonize the effect of vecuronium
  • Risk C: monitor therapy
• Aminoglycosides (see Aminoglycosides): aminoglycosides enhance the effect of vecuronium
  • Risk C: monitor therapy
• Calcium Channel Blockers (see Calcium Channel Blockers): calcium channel blockers enhance the paralytic effect of non-depolarizing neuromuscular junction antagonists
  • Risk C: monitor therapy
• Cardiac Glycosides (Digoxin) (see Digoxin): neuromuscular junction antagonists may enhance the arrhythmogenic effect of cardiac glycosides
  • Risk C: monitor therapy
• Colistin (Polymyxin E, Colistimethate Sodium) (see Colistin)
  • Risk D: consider therapy modification
• Corticosteroids (see Corticosteroids): concomitant use of vecuronium and corticosteroids is associated with the development of neuropathy/myopathy
  • Risk D: consider therapy modification
• Cyclosporine A (CSA) (see Cyclosporine A): cyclosporine A enhances the effect of neuromuscular junction antagonists
  • Risk C: monitor therapy
• Inhalational Anesthetics: inhalational anesthetics enhance the effect of vecuronium
  • Risk C: monitor therapy
• Ketorolac (see Ketorolac): ketorolac enhances the effect of neuromuscular junction antagonists (episodes of apnea have been reported with this combination)
  • Risk C: monitor therapy
• Loop Diuretics (see Furosemide and Bumetanide): loop diuretics enhance the effect of neuromuscular junction antagonists
  • Risk C: monitor therapy
• Piperacillin (see Piperacillin-Tazobactam): piperacillin enhances the effect of neuromuscular junction antagonists
  • Risk C: monitor therapy
• Spironolactone (Aldactone) (see Spironolactone): spironolactone enhances the effect of neuromuscular junction antagonists
  • Risk C: monitor therapy
• Tetracyclines (see Tetracyclines): tetracyclines enhance the effect of neuromuscular junction antagonists
  • Risk C: monitor therapy
• Vancomycin (see Vancomycin): vancomycin enhances the effect of neuromuscular junction antagonists
  • Risk C: monitor therapy

Reversal of Neuromuscular Blockade

• Sugammadex (Bridion) (see Sugammadex)

Allergic/Immunologic Adverse Effects

Anaphylaxis/Anaphylactoid Reaction (see Anaphylaxis)

• Epidemiology
  • Cross-Reactivity: cross-reactivity with other neuromuscular junction antagonists may occur (when anaphylaxis has previously occurred with other agent)
  • Relative Incidence of Anaphylaxis with Neuromuscular Junction Antagonists (in Australian Study from 2002-2011): Rocuronium (56% of cases) > Succinylcholine (21% of cases) > Vecuronium (11% of cases) (Br J Anaesth, 2013) [MEDLINE]
    • Cisatracurium Had the Lowest Prevalence of Cross-Reactivity in Patients with Known Anaphylaxis to Either Rocuronium or Vecuronium

Neurologic Adverse Effects

Exacerbation of Myasthenia Gravis (see Myasthenia Gravis)

• Epidemiology
  • Vecuronium Has a Clear Effect on Myasthenia Gravis

Intensive Care Unit (ICU)-Acquired Weakness (see Intensive Care Unit-Acquired Weakness)

• Epidemiology
  • Prolonged Weakness/Paralysis May Occur After Extended Use of Neuromuscular Junction Antagonists, Especially in Conjunction with Corticosteroids (see Neuromuscular Junction Antagonists and Corticosteroids)

Prolonged Paralysis

• Epidemiology
  • Prolonged Weakness/Paralysis May Occur After Extended Use of Neuromuscular Junction Antagonists, Especially in Conjunction with Corticosteroids (see Neuromuscular Junction Antagonists and Corticosteroids)

Toxicologic Adverse Effects

Bromism (see Bromide)

• Mechanism
  • Due to Formulation as Vecuronium Bromide
• Clinical
  • Bromoderma
  • Decreased/Negative Serum Anion Gap (see Serum Anion Gap)
  • Obtundation/Coma (see Obtundation-Coma)