Acetylcholinesterase inhibitor
Neostigmine + glycopyrrolate
Bloxiverz NMB reversal — red/white stripes Neostigmine 1 mg/mLGlycopyrrolate 0.2 mg/mL
Classic reversal — works only when the block is already wearing off.
Typical adult doses
| Indication | Dose | Onset | Duration |
|---|---|---|---|
| Neostigmine | 0.03–0.07 mg/kg IV (max 0.07 mg/kg or 5 mg) | Peak ≈10 min | — |
| Glycopyrrolate (given with it) | 0.2 mg per 1 mg neostigmine | — | — |
Mechanism
Inhibits acetylcholinesterase → more ACh competes with the NMB. Glycopyrrolate blocks muscarinic side effects.
Key effects
- Bradycardia, secretions, bronchospasm, GI motility if given without an anticholinergic
Watch out for
- ASA 2023: reasonable only at minimal depth (TOF ratio 0.4 to < 0.9); use sugammadex for deep, moderate or shallow block
- Ceiling effect — cannot reverse a deep block
- Still confirm quantitative TOF ratio ≥ 0.9 before extubation
Pimp questions
Pimp question 1
Why glycopyrrolate with neostigmine rather than atropine?
Answer
Similar onset timing, and glycopyrrolate does not cross the blood–brain barrier.
Pimp question 2
Can neostigmine reverse a TOF count of 0?
Answer
No — too many receptors are occupied (ceiling effect).