When should neostigmine not be used for NMB reversal?

Neostigmine should not be used for profound blockade (TOF count 0 to 1 or PTC 0 to 1) - will not achieve adequate reversal and may increase risk of PORC. In these cases, wait for spontaneous recovery to TOF 2+ or use sugammadex (not effective for benzylisoquinolines but wait is required or accept incomplete reversal).

What dose of glycopyrrolate accompanies neostigmine?

Glycopyrrolate 0.1 to 0.2 mg per 1 mg neostigmine (or full dose 0.2 to 0.3 mg IV total, mixing in same syringe). Glycopyrrolate preferred over atropine: slower onset matches neostigmine kinetics, reduces bronchospasm risk (does not cross BBB). Atropine 0.01 mg/kg acceptable alternative but may cause tachycardia and delirium risk from CNS penetration.

Neostigmine Dose for Neuromuscular Blockade Reversal

Calculate neostigmine dose (0.03 to 0.07 mg/kg IV, max 5 mg) for reversal of non-depolarizing NMB at adequate block depth (TOF >=2 twitches), always given with glycopyrrolate or atropine.

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Frequently Asked Questions

When should neostigmine not be used for NMB reversal?

What dose of glycopyrrolate accompanies neostigmine?