Neostigmine
Bloxiverz
Acetylcholinesterase inhibitor
Reversibly inhibits AChE → ↑ACh at NMJ → outcompetes non-depolarizing relaxants. Co-administer antimuscarinic (glycopyrrolate or atropine) to block muscarinic side effects.
Indications
- •NDMR reversal
- •Myasthenia gravis maintenance
Dosing
| Context | Adult | Pediatric |
|---|---|---|
| NMB reversal | 0.04–0.07 mg/kg IV (max 5 mg) + glycopyrrolate 0.2 mg per 1 mg neo | 0.05–0.07 mg/kg IV |
Pharmacokinetics
Onset 5–10 min. Duration 60 min. Renal + hepatic clearance.
Hemodynamic effects
Bradycardia, ↓BP if antimuscarinic not given.
Side effects
- !Bradycardia, asystole
- !Bronchoconstriction, ↑secretions
- !↑GI motility (problematic for fresh anastomoses?)
- !PONV
Contraindications
- ×Mechanical bowel/urinary obstruction
- ×Asthma (relative)
Clinical pearls
- ★Don't reverse 0 twitches — give time or use sugammadex.
- ★Maximum reversal at TOF count ≥ 2; ratio ≥ 0.9 needed for safe extubation.
- ★Glyco preferred over atropine — matches neostigmine onset and avoids tachycardia.
Education only — confirm against current package inserts and institutional protocols. Doses assume normal organ function unless otherwise noted.