Usual Adult Dose for Reversal of Neuromuscular Blockade

Initial dose: 0.03 to 0.07 mg/kg IV over a period of at least 1 minute
Maximum dose: 0.07 mg/kg IV or up to a total of 5 mg IV, whichever is less

Comments:

• Administer an anticholinergic agent (e.g., atropine, glycopyrrolate) IV prior to or concomitantly with this drug using a separate syringe. In the presence of bradycardia, administer the anticholinergic prior to this drug.
• Patient should be well ventilated.
• Use a peripheral nerve stimulator to determine initiation time and need for additional doses.

NOTE:

• Peripheral nerve stimulation devices capable of delivering a train-of-four (TOF) stimulus are essential to effectively using this drug.
• There must be a twitch response to the first stimulus in the TOF of at least 10% of its baseline level (i.e., the response prior to NMBA administration, prior to the administration of this drug).
• A 0.03 to 0.07 mg/kg dose will generally achieve a TOF twitch ratio of 90% within 10 to 20 minutes. Dose selection should be based on the extent of spontaneous recovery that has occurred at the time of administration, the half-life of the NMBA being reversed, and whether there is a need to rapidly reverse the NMBA.
• The 0.03 mg/kg dose is recommended for:

a) Reversal of NMBAs with shorter half-lives (e.g., rocuronium)
or
b) When the first twitch response to the TOF stimulus is substantially greater than 10% of baseline or when a second twitch is present.

• The 0.07 mg/kg dose is recommended for:

a) NMBAs with longer half-lives (e.g., vecuronium, pancuronium)
or
b) When the first twitch response is relatively weak (i.e., not substantially greater than 10% of baseline)
or
c) There is need for more rapid recovery.

• TOF monitoring should continue to be used to evaluate the extent of recovery of neuromuscular function and the possible need for an additional dose.
• TOF monitoring alone should not be relied upon to determine the adequacy of reversal of neuromuscular blockade as related to a patient's ability to adequately ventilate and maintain a patent airway following tracheal extubation.
• Patients should continue to be monitored for adequacy of reversal from NMBAs for a period that would assure full recovery based on the patient's medical condition and the pharmacokinetics of neostigmine and the NMBA used.

Use: For the reversal of the effects of non-depolarizing neuromuscular blocking agents (NMBAs) after surgery

Usual Pediatric Dose for Reversal of Neuromuscular Blockade

Initial dose: 0.03 to 0.07 mg/kg IV over a period of at least 1 minute
Maximum dose: 0.07 mg/kg IV or up to a total of 5 mg IV, whichever is less

Comments:

• Administer an anticholinergic agent (e.g., atropine, glycopyrrolate) IV prior to or concomitantly with this drug using a separate syringe. In the presence of bradycardia, administer the anticholinergic prior to this drug.
• Patient should be well ventilated.
• Use a peripheral nerve stimulator to determine initiation time and need for additional doses.

NOTE:

• Peripheral nerve stimulation devices capable of delivering a train-of-four (TOF) stimulus are essential to effectively using this drug.
• There must be a twitch response to the first stimulus in the TOF of at least 10% of its baseline level (i.e., the response prior to NMBA administration, prior to the administration of this drug).
• A 0.03 to 0.07 mg/kg dose will generally achieve a TOF twitch ratio of 90% within 10 to 20 minutes. Dose selection should be based on the extent of spontaneous recovery that has occurred at the time of administration, the half-life of the NMBA being reversed, and whether there is a need to rapidly reverse the NMBA.
• The 0.03 mg/kg dose is recommended for:

a) Reversal of NMBAs with shorter half-lives (e.g., rocuronium)
or
b) When the first twitch response to the TOF stimulus is substantially greater than 10% of baseline or when a second twitch is present.

• The 0.07 mg/kg dose is recommended for:

a) NMBAs with longer half-lives (e.g., vecuronium, pancuronium)
or
b) When the first twitch response is relatively weak (i.e., not substantially greater than 10% of baseline)
or
c) There is need for more rapid recovery.

• TOF monitoring should continue to be used to evaluate the extent of recovery of neuromuscular function and the possible need for an additional dose.
• TOF monitoring alone should not be relied upon to determine the adequacy of reversal of neuromuscular blockade as related to a patient's ability to adequately ventilate and maintain a patent airway following tracheal extubation.
• Patients should continue to be monitored for adequacy of reversal from NMBAs for a period that would assure full recovery based on the patient's medical condition and the pharmacokinetics of neostigmine and the NMBA used.

Use: For the reversal of the effects of non-depolarizing neuromuscular blocking agents (NMBAs) after surgery

Renal Dose Adjustments

No adjustment recommended.

Liver Dose Adjustments

No adjustment recommended.

Precautions

CONTRAINDICATIONS:

• Hypersensitivity to the active component or any of the ingredients

with peritonitis or mechanical obstruction of the intestinal or urinary tract.

Consult WARNINGS section for additional precautions.

Dialysis

Data not available

Other Comments

Administration advice:

• This drug should be administered by trained healthcare providers familiar with the use, actions, characteristics, and complications of neuromuscular blocking agents (NMBA) and neuromuscular block reversal agents.
• Doses should be individualized and a peripheral nerve stimulator should be used to determine the time of initiation of this drug and should be used to determine the need for additional doses.
• Prior to administration of this drug and until complete recovery of normal ventilation, the patient should be well ventilated, and a patent airway maintained. Satisfactory recovery should be judged by adequacy of skeletal muscle tone and respiratory measurements in addition to the response to peripheral nerve stimulation.
• An anticholinergic agent (e.g., atropine sulfate, glycopyrrolate) should be administered prior to or concomitantly with this drug.
• This drug has a slower onset of effect when given orally than when given parenterally, but the duration of action is longer and the intensity of action more uniform.
• To facilitate change of treatment from one route of administration to another, the following doses are approximately equivalent in effect: 0.5 mg IV = 1 to 1.5 mg IM or subcutaneously = 15 mg orally.