Reversal Agents - Neostigmine Flashcards
Intense – period of no response, 3 – 6 minutes after intubating dose of non-depolarizing NMBD
-Neostigmine reversal impossible; high dose of sugammadex (16 mg/kg) for reversal
Deep – absence of TOF but presence of at least one response to post-tetanic count stimulation
-Neostigmine reversal usually impossible; dose of sugammadex (4 mg/kg) for reversal
Moderate – gradual return of the 4 responses to TOF stimulation appears
-Neostigmine reversal after 4/4 TOF; dose of sugammadex (2 mg/kg) for reversal
What is the recommended dose range for Neostigmine? (Select 2)
a) 50-70 mcg/kg IV
b) Up to 80 mcg/kg IV
c) 5 mg IV as a maximum dose
d) 10 mg IV
a) 50-70 mcg/kg IV,
c) 5 mg IV as a maximum dose
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
TxWes Reference:
0.04 - 0.07 mg/kg
onset: 5 - 10 mins
duration: 60 mins
Glycopyrrolate 0.2 mg per mg of Neostigmine
What is the concentration of Neostigmine in a vial? (Select all that apply)
a) 1 mg/mL
b) 5 mg/mL
c) 10 mg/mL
d) 0.5 mg/mL
a) 1 mg/mL
What is the onset time for Neostigmine? (Select all that apply)
a) 1-2 minutes
b) 5-10 minutes
c) 15-20 minutes
d) 30 minutes
b) 5-10 minutes
Which of the following describes the mechanism of action (MOA) of Neostigmine? (Select 3)
a) Acetylcholinesterase inhibitor
b) Cholinergic agent
c) Competitive antagonist
d) Depolarizing agent
a) Acetylcholinesterase inhibitor,
b) Cholinergic agent,
c) Competitive antagonist
How is Neostigmine metabolized and what are the characteristics of its metabolites? (Select 3)
a) 25-50% of Neostigmine is metabolized hepatically.
b) Neostigmine is metabolized to an active metabolite that is as potent as the parent drug.
c) The active metabolite is approximately 1/10 as potent as Neostigmine.
d) The majority of Neostigmine is eliminated unchanged in the urine.
a) 25-50% of Neostigmine is metabolized hepatically,
c) The active metabolite is approximately 1/10 as potent as Neostigmine,
d) The majority of Neostigmine is eliminated unchanged in the urine
Elimination: METAB: 25-50% hepatic. active metabolite (1/10 as potent) ELIM: 50-75% renal, unchanged. Prolonged severe renal fail (OK with prolonged NMB)
What should be noted about the effectiveness of Neostigmine in deep neuromuscular block? (Select 2)
a) Neostigmine is effective in reversing deep neuromuscular block at doses above 80 mcg/kg.
b) Neostigmine will not be effective in deep neuromuscular block if the dose exceeds 80 mcg/kg.
c) A ceiling effect occurs at 80 mcg/kg, beyond which Neostigmine does not provide additional benefit.
d) Neostigmine can reverse any depth of neuromuscular block if used at a high enough dose.
b) Neostigmine will not be effective in deep neuromuscular block if the dose exceeds 80 mcg/kg,
c) A ceiling effect occurs at 80 mcg/kg, beyond which Neostigmine does not provide additional benefit
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
What is the approximate half-life of Neostigmine? (Select all that apply)
a) 30 minutes
b) 60 minutes
c) 90 minutes
d) 120 minutes
Answer: b) 60 minutes
Which of the following are muscarinic cholinergic effects associated with Neostigmine? (Select all that apply)
a) Miosis
b) Urination
c) Diarrhea
d) Diaphoresis
e) Lacrimation
f) Excitation (CNS)
g) Salivation
a) Miosis,
b) Urination,
c) Diarrhea,
d) Diaphoresis,
e) Lacrimation,
f) Excitation (CNS),
g) Salivation
MUSCARINIC CHOLINERGIC effects: MUDDLES
Pre-treat with anticholinergic Glycopyrrolate (antimuscarinic)
In which patient population is Neostigmine particularly prioritized for use?
a) Renal patients
b) Hepatic patients
c) Patients with normal renal function
d) Patients with cardiovascular diseases
a) Renal patients
What is the primary classification of Neostigmine? (Select all that apply)
a) Carbamate
b) Quaternary amine
c) Benzylisoquinolinium
d) Depolarizing agent
a) Carbamate
b) Quaternary amine
Action: Carbamate (quaternary amine) NMBD Reversal agent; priority used when renal pt; allows increased ACh at NMJ.
Why is have preferably 2 twitches important before administering Neostigmine for neuromuscular blockade reversal? (Select 2)
a) To ensure that Neostigmine can effectively reverse the blockade at multiple neuromuscular junction sites.
b) To confirm that the neuromuscular blockade is completely resolved.
c) To avoid recurarization, which can occur if the blockade is too deep and only a few receptor sites are available.
d) To ensure that the patient is fully conscious before administering the reversal agent.
a) To ensure that Neostigmine can effectively reverse the blockade at multiple neuromuscular junction sites,
c) To avoid recurarization, which can occur if the blockade is too deep and only a few receptor sites are available
If you have 0/4, you will just be competitively reversing the few sites available and will have recurarization.
What is the minimum number of twitches required to effectively use Neostigmine for reversing neuromuscular blockade? (Select all that apply)
a) 0 twitches
b) 1-2 twitches
c) 3 twitches
d) 4 twitches
b) 1-2 twitches
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.
What precautions should be taken when using Neostigmine in elderly patients? (Select 2)
a) Neostigmine’s duration of action may be prolonged in elderly patients.
b) Elderly patients typically require higher doses of Neostigmine.
c) Monitor for potential recurarization due to prolonged neuromuscular blockade.
d) There is no need for dose adjustment in elderly patients.
a) Neostigmine’s duration of action may be prolonged in elderly patients,
c) Monitor for potential recurarization due to prolonged neuromuscular blockade
What is a key characteristic of Neostigmine regarding its interaction with the blood-brain barrier (BBB)?
a) Neostigmine passes through the BBB.
b) Neostigmine does not pass through the BBB.
c) Neostigmine can cause central nervous system effects despite not crossing the BBB.
b) Neostigmine does not pass through the BBB
Pre-treat with anticholinergic Glycopyrrolate (antimuscarinic)
