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Acetylcholinesterase Inhibitor / Neuromuscular Blockade Reversal Pregnancy: C

Neostigmine

Brand names: Neostigmine Methylsulfate

Adult dose

Dose: 2.5mg IV (with glycopyrrolate 0.5mg IV to prevent muscarinic side effects)
Route: IV
Frequency: Single dose
Max 5mg. Always give WITH glycopyrrolate (or atropine 1.2mg). Only use when at least T2 present on TOF monitoring.

Paediatric dose

Dose: 0.05 mg/kg
Route: IV
Frequency: Single dose
Max: 2.5mg
Give with glycopyrrolate 0.01mg/kg IV. Do not exceed 2.5mg.
Paediatric weight-based calculator

Give with glycopyrrolate 0.01mg/kg IV. Do not exceed 2.5mg.

Clinical pearls

  • ALWAYS co-administer glycopyrrolate or atropine to counteract muscarinic effects (bradycardia, secretions)
  • Less effective than sugammadex — ceiling effect; incomplete reversal at deep block
  • Do NOT use at T0 (no TOF count) — may induce fade pattern
  • Oral neostigmine: used in myasthenia gravis management (completely different indication)
  • Glycopyrrolate preferred over atropine (does not cross BBB — fewer central effects)

Contraindications

  • Intestinal obstruction
  • Urinary tract obstruction
  • Bradycardia without atropine co-administration

Side effects

  • Bradycardia (muscarinic — blocked by glycopyrrolate)
  • Excessive secretions
  • Bronchoconstriction
  • GI cramping
  • Miosis

Interactions

  • Aminoglycosides — antagonise reversal
  • Volatile anaesthetics — slow reversal

Monitoring

  • TOF ratio (confirm ≥0.9 before extubation)
  • HR and SpO2 post-reversal

Reference: BNFc; AAGBI Guidelines; BNF. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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