Evaluation of the Efficacy and Safety of Neostigmine in Reversing Neuromuscular Blockade

• Published in: Current anesthesiology reports (Philadelphia) 2020-06, Vol.10 (2), p.85-89
• Main Authors: Schmartz, D., Bernard, P., Sghaier, R., Fuchs-Buder, T.
• Format: Article
• Language: English
• Subjects: Anesthesiology; Critical Care Medicine; Intensive; Internal Medicine; Medicine; Medicine & Public Health; Neuromuscular Blockade (GS Murphy; Section Editor; Topical Collection on Neuromuscular Blockade
• ISSN: 2167-6275; 2167-6275
• DOI: 10.1007/s40140-020-00392-8

Purpose of Review The minimum degree of neuromuscular recovery required before extubating the patient has progressively increased from a train-of-four ratio of 0.7 to a train-of-four ratio ≥ 0.9. The aim of the review is to evaluate the efficacy and the safety of neostigmine in antagonizing nondepolarizing neuromuscular block considering the new endpoint. Recent Findings Increasing evidence suggests limited efficacy of neostigmine when a TOF ratio ≥ 0.9 is considered as appropriate endpoint. Summary The currently accepted endpoint of adequate neuromuscular recovery challenges the efficacy of neostigmine. At least under volatile anesthesia, neostigmine can no longer be considered as an efficient drug to reverse moderate neuromuscular blockade, but it still allows to accelerate neuromuscular recovery when given at more advanced degrees of spontaneous recovery (i.e., a TOF ratio ≥ 0.4). Moreover, neostigmine-based reversal is associated with a higher incidence of adverse effects compared with sugammadex.