Reevaluation and update on efficacy and safety of neostigmine for reversal of neuromuscular blockade

Abstract

Postoperative residual neuromuscular block is a serious threat which endangers the patient safety. Neostigmine has been the most commonly used anticholinesterase for the pharmacological reversal of neuromuscular blockade. Although newer agents have been introduced recently, neostigmine has some irreplaceable advantages, including broad-spectrum reversal of all nondepolarizing neuromuscular blocking drugs, low cost, and availability of more related data for clinical practice to refer to. Neostigmine is also noticed to have some drawbacks, such as the inability to reverse profound and deep blockade, potential induction of muscle weakness, cardiovascular adverse effects, and so on. Data on the usage of neostigmine in the geriatric and the pediatric population are still insufficient. Some discrepancies are observed in the results from previous studies which need further investigation. However, recent studies offer some renewed information. Regarding both efficacy and safety, the key for successful reversal of neuromuscular blockade is to use neostigmine “appropriately,” optimizing the dosage and timing of administration under close monitoring.

Comparison of postoperative pulmonary complications between sugammadex and neostigmine in lung cancer patients undergoing video-assisted thoracoscopic lobectomy: a prospective double-blinded randomized trial

“…As a cholinesterase inhibitor, neostigmine mainly inhibits acetylcholine breakdown, increases acetylcholine levels in the neuromuscular junction, and enhances the ability of acetylcholine to compete with non-depolarized muscle relaxants at the receptor [ 3 , 7 ]. However, in several studies on the routine use of neostigmine, the incidence of PRNMB on arrival to the post-anesthesia care unit did not change.…”

Recovery from Anesthesia after Robotic-Assisted Radical Cystectomy: Two Different Reversals of Neuromuscular Blockade

“…Moreover, in the study by Yağan, neostigmine doses were higher than those used in our study [13], and the correlation between the neostigmine dose and PONV is now considered a key factor to control the symptoms [9].…”

“…Neostigmine has been associated with an increased incidence of postoperative nausea and vomiting (PONV), although there is no definitive agreement on the need to avoid its use to reduce the incidence of PONV [9]. On the other hand, neostigmine has an important muscarinic effect on gastrointestinal (GI) receptors, and, by increasing the availability of acetylcholine, increases the GI motility.…”

Comment on: Does sugammadex decrease the severity of agitation and complications in pediatric patients undergoing adenotonsillectomy?

“…Therefore, the timing of neostigmine administration has not been fully understood, which is now being a research of interest for further studies. 4 The information given in comments of the author is absolutely accurate; however, the recommendations merely belongs to the adults population, they are neither for pediatric nor geriatric population.…”