Anticholinesterase (Reversal Agent)
Pregnancy: Compatible — used routinely in obstetric anaesthesia for reversal
Neostigmine
Brand names: Neostigmine (generic), Robinul-Neostigmine (with glycopyrrolate)
Adult dose
Dose: Reversal of NMB: 50 mcg/kg IV (max 5 mg), always with glycopyrrolate 10–15 mcg/kg (or atropine 20 mcg/kg) to block muscarinic effects
Route: IV
Frequency: Single dose for reversal
Max: 5 mg
Always co-administer with anticholinergic (glycopyrrolate or atropine) — neostigmine causes bradycardia, increased secretions, and bronchospasm via muscarinic activation. Do NOT use for reversal of deep NMB (TOF count <2 twitches) — use sugammadex instead.
Paediatric dose
Dose: 0.05 mg/kg
Route: IV
Frequency: Single dose
Max: 5 mg
Concentration: 2.5 mg/mL mg/ml
Always with glycopyrrolate 10 mcg/kg or atropine 20 mcg/kg. Same indication as adults.
Dose adjustments
Renal
Reduced clearance in renal impairment — may prolong reversal effect (rarely clinically significant)
Hepatic
No significant adjustment required
Paediatric weight-based calculator
Always with glycopyrrolate 10 mcg/kg or atropine 20 mcg/kg. Same indication as adults.
Clinical pearls
- Never give neostigmine without anticholinergic cover — can cause severe bradycardia or cardiac arrest
- Not effective for deep NMB (TOF count 0–1) — use sugammadex (rocuronium/vecuronium), or wait for spontaneous recovery
- Re-curarisation risk: neostigmine effect wears off before NMB — monitor TOF before extubation
- Neostigmine also used for myasthenia gravis treatment (different dose — 15–30 mg oral every 4h)
Contraindications
- Mechanical bowel/urinary obstruction
- Depolarising neuromuscular blockade (suxamethonium — phase 1)
- Asthma (relative — bronchospasm risk)
Side effects
- Bradycardia (blocked by anticholinergic co-administration)
- Increased secretions
- Nausea/vomiting
- Abdominal cramping
- Bronchospasm (asthmatic patients)
- Miosis
Interactions
- Anticholinergics — counteract muscarinic effects (required co-administration)
- Suxamethonium — prolongs depolarising blockade if given during phase 1 (do not use for phase 1 reversal)
Monitoring
- Train-of-four before and after reversal (TOF ratio >0.9 before extubation)
- Heart rate (bradycardia)
- Respiratory function
- SpO2
Reference: BNFc; BNF; RCoA Safe Anaesthesia Liaison Group (SALG); Miller's Anaesthesia. Verify against your local formulary and the latest BNF before prescribing.
Related
Curated clinical cross-links plus same-class fallbacks.