A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose?
1. Leg movement
A. Leg movement
B. Finger movement
C. Lip movement
D. Fighting the ventilator
Correct Answer: D. Fighting the ventilator
Pancuronium, a non-depolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting endotracheal intubation and paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the legs, or lips has no effect on the ventilator and therefore is not used to determine the need for another dose.
Option A: Leg movement is not used as an indication for another dose. Pancuronium bromide is a long-acting, bis-quaternary aminosteroid, non-depolarizing, neuromuscular blocking drug (NMBD), which was first synthesized in 1964 and found to possess fewer adverse effects with regards to hemodynamic stability and histamine release as compared to the prototypical NMBD, d-tubocurarine.
Option B: Finger movement does not determine if the client needs another dose. Pancuronium administration is by intravenous bolus. A continuous IV infusion may be a consideration in the management of critically ill patients.
Option C: Lip movement does not indicate that the patient needs another dose. The typical intubating dose is 0.1 mg/kg with a 3 to 5-minute onset to maximal muscle relaxation. The 95% effective dose is 0.07 mg/kg. There is a 60- to the 90-minute duration of action (return to 25% of control twitches) with a typical intubating dose. Maintenance of neuromuscular blockade is possible with a dose of 0.02 mg/kg, titrated to the level of blockade.
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