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After developing severe respiratory problems, a 79-year-old woman was intubated and placed on a ventilator. She was tachycardic and restless; her respirations were 48.
The intensive care unit (lCU) nurse who was suctioning her met with some resistance, but she continued the procedure and told another nurse that everything was fine. Soon, the ventilator alarms went off, indicating that the patient was bucking the ventilator or otherwise exerting negative pressure.
The nurse immediately called the doctor, who ordered I.V. morphine, 10 mg, to relax her. When that didn't work, she called him again and he ordered pancuronium bromide (Pavulon), a neuromuscular blocker that paralyzes restless patients and allows the ventilator to take over respirations.
Minutes after the drug was administered, the patient's respirations stopped and her heart rate dropped to 30. Manual bagging didn't help, although atropine did restore her heart rate. After vigorous suctioning, the nurse removed a large mucus plug. Ventilation was resumed, but the patient died several days later.
In another case, a doctor ordered Pavulon for a ventilator patient, to be given "p.r.n. for agitation." The patient was doing well and began breathing on his own, so he no longer needed the ventilator.
After a family visit, though, he became flustered and seemed so disturbed that a new lCU nurse checked the medication administration record to see if his doctor had written an order for an antianxiety drug. She saw that Pavulon had been ordered for agitation. Although unfamiliar with Pavulon, she took the drug from the medication cabinet and administered it. Immediately, the patient went into respiratory arrest. A code was called and he was resuscitated, but not before permanent brain damage.
Both examples show that neuromuscular blocking agents like Pavulon require specific protocols that include the following cautions: