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Anticholinergic (Muscarinic Antagonist) — Perioperative Pregnancy: Used intraoperatively — crosses placenta minimally

Glycopyrronium (Perioperative — Anticholinergic)

Brand names: Robinul

Adult dose

Dose: With neostigmine (reversal): 200–400 mcg IV with each 2.5 mg neostigmine IV (ratio 1:5 glycopyrronium:neostigmine by weight). Antisialagogue (pre-op secretions): 200 mcg IV/IM. Bradycardia: 200–400 mcg IV
Route: IV or IM
Frequency: Single dose (reversal/pre-op); repeat if needed (bradycardia)
Max: 400 mcg per dose; titrate to HR
Does NOT cross blood-brain barrier (quaternary ammonium compound) — no CNS effects. Preferred over atropine as reversal adjunct — smoother HR control. Duration of antisialagogue effect 4–8h. Can be mixed with neostigmine in same syringe.

Paediatric dose

Dose: 0.01 mg/kg
Route: IV
Frequency: Single dose with neostigmine
Max: 0.2 mg per dose
Concentration: 200 mcg/mL mg/ml
Children: 0.01 mg/kg IV with neostigmine. Neonates: 0.01 mg/kg IV with neostigmine 0.05 mg/kg — always co-administer.

Dose adjustments

Renal

No dose adjustment required

Hepatic

No dose adjustment required

Paediatric weight-based calculator

Children: 0.01 mg/kg IV with neostigmine. Neonates: 0.01 mg/kg IV with neostigmine 0.05 mg/kg — always co-administer.

Clinical pearls

  • No CNS penetration: unlike atropine, glycopyrronium does not cross the blood-brain barrier — no central anticholinergic effects (agitation, delirium)
  • Preferred over atropine for neostigmine reversal co-administration: duration better matched to neostigmine (both 30–60 min)
  • Antisialagogue: given pre-operatively for procedures with high secretion risk (airway surgery, bronchoscopy, paediatric intubation)
  • Bronchial smooth muscle relaxation: reduces respiratory secretions intraoperatively
  • Robinul-Neostigmine combined preparation: available as pre-mixed syringe in some formularies

Contraindications

  • Glaucoma (angle-closure)
  • Pyloric stenosis
  • Paralytic ileus
  • Urinary retention (BPH)

Side effects

  • Tachycardia
  • Dry mouth
  • Urinary retention
  • Constipation
  • Blurred vision
  • No CNS side effects (unlike atropine — does not cross BBB)

Interactions

  • Neostigmine — always co-administered to counteract muscarinic effects of reversal
  • Other anticholinergics — additive effects

Monitoring

  • Heart rate (tachycardia)
  • Urinary output (urinary retention risk)
  • Secretion control (antisialagogue effect)

Reference: BNFc; BNF; AAGBI Reversal of Neuromuscular Block Guidelines; RCoA Anaesthetic Guidelines. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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