title: Contraindications - Neonatal Intensive Care Drug Manual
text: Avoid prolonged usage.
  Suggest regular cessation of infusion, possibly every 24 hours (commonly referred to as ‘drug holiday’) to assess the need for continued paralysis and adequacy of sedation or analgesia.
  Pre-existing tachycardia, hypertension (including that associated with renal failure or phaeochromocytoma)—consider an alternative agent.
  Renal: Prolonged neuromuscular blockade may occur in renal impairment; reduction in maintenance dose may be necessary.
  Hepatic: Increased onset time and prolonged duration of action may occur in impairment; consider using alternative agent.
  Myasthenia gravis—prolongs paralysis; avoid neuromuscular blocking agents if possible.
  Neuromuscular diseases (e.g. dystrophia myotonica, history of polio), severe obesity—unpredictable effect; use cautiously and monitor neuromuscular function closely.
  Neonates are generally more sensitive to non-depolarising neuromuscular blocking agents; duration of action may be prolonged; monitor neuromuscular function closely.
  Acidosis, dehydration, hypokalaemia, hypermagnesaemia, hypocalcaemia—enhances effects of neuromuscular blocking drugs; where possible correct before administration, reduce dose and monitor neuromuscular blockade.
  Hypothermia—decreases effect of pancuronium (unlike the rest of the neuromuscular blockers); reduce dose and monitor neuromuscular blockade.
  Anaphylactic reaction to neuromuscular blocking agents—allergic cross-reactivity has been reported; refer to specialist for skin testing for sensitivity to other neuromuscular blockers.
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