REVERSAL AGENTS for NMBs

Question 1

· Neostigmine/Bloxiverz,

Answer 1

o Dose Range: 50-70 mcg/kg to max 5 mg (ceiling effect at 80 mcg/kg and will not work in deep NM block) or 5mg Neo with 1 mg Glyco
o Concentration: 1mg/mL
o Onset: 5-10 minutes
o ½ Life: 60 minute duration (will give glycopyrrolate d/t similar duration)
o When to use: You MUST have 1-2 twitches, preferably 2, in order to successfully reverse the patient. If you have 0/4, you will just be competitively reversing the few sites available and will have recurarization.
o Precautions: duration prolonged in elderly and renal failure (same with NMBDs. So all good); watch out for recurarization in OR;
o S/E: MUSCARINIC CHOLINERGIC effects: MUDDLES (Miosis, Urination, Diarrhea, Diaphoresis, Lacrimation, Excitation- CNS, Salivation). NAUSEA; Increased secretions= laryngospasm. Bradycardia/ ASYSTOLE. Doesn’t pass BBB. Pre-treat with anticholinergic Glycopyrrolate (antimuscarinic)

Question 2

· Glycopyrrolate/Cuvposa, Dartisla ODT, Glycopyrronium, Robinul, Robinul Forte

Answer 2

o Dose Range: 10-20 (15) mcg/kg (0.2 mg/mL) or 0.2 mg for each 1mg neostigmine
-you will be dosing glycopyrrolate first before neostigmine, give in increments of 0.2 mg so you dont cause too much tachycardia.
o Concentration: 0.2mg/mL
o Onset: 2-3 minutes
o ½ Life: 2 hr duration
o C/I: Closed-angle glaucoma, caution c autonomic neuropathy (MG), unstable CV status
o Precautions: Tachycardia ++, Bronchodilation ++, Antisialogogue +++, does not block all s/e of reversal drugs (nausea still issue)

Question 3

· Sugammadex/Bridion (Used at ARMC if you have 0/4 twitches and case is done or when infiltration is seen after reversing)

Answer 3

o Dose Range: 4 mg/kg if TOF 2 twitches; 16 mg/kg if deep block from recent NMBD
o Onset: 3 minutes
o ½ Life: 2 hours (depends on renal function; up to 19 hours in severe impairment)
C/I: In hypersensitivity to Sugammadex (0.3%) in past or cyclodextrins.
o Precautions: No cholinergic effects (bradycardia); watch with renal impairment and hormonal contraceptives (lowering of free plasma concs); No effect on benzylisoquinoline NMBDs