reversal agent

Neostigmine

Bloxiverz

Route: IV
Onset: 1–3 minutes; peak effect about 7–10 minutes
Duration: About 40–90 minutes

Mechanism of action

Acetylcholinesterase inhibitor. Raises acetylcholine at the neuromuscular junction to compete with non-depolarizing blockers. Also raises acetylcholine at muscarinic sites, causing bradycardia, secretions and bronchospasm unless an anticholinergic is given with it.

Dosing

Adult: 0.03–0.07 mg/kg IV (max 5 mg), with glycopyrrolate about 0.2 mg per 1 mg of neostigmine
Pediatric: 0.03–0.07 mg/kg IV with glycopyrrolate or atropine

Give only once spontaneous recovery has started (at least 2, ideally 4, twitches on train-of-four).

Indications

Reversal of residual non-depolarizing neuromuscular block (rocuronium, vecuronium, cisatracurium)
Myasthenia gravis (pyridostigmine is usually preferred for maintenance)

Contraindications

Mechanical bowel or urinary obstruction
Hypersensitivity
Use with caution in asthma, bradycardia and recent myocardial infarction

Side effects

Bradycardia, heart block
Bronchospasm and increased bronchial secretions
Salivation, nausea, abdominal cramping
Weakness if given without residual block (cholinergic)

Monitoring parameters

Train-of-four ratio ≥0.9 before extubation
Heart rate
Bronchospasm and secretions

Drug interactions

Prolongs succinylcholine block
Anticholinergics (glycopyrrolate, atropine) offset muscarinic effects

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