Neostigmine: Side Effects

Basic, Organ-Based and Clinical Sciences

When neostigmine is administered to reverse neuromuscular blockade, the nicotinic effects are desired but muscarinic effects can be problematic.

Cardiovascular:

  • Muscarinic effect results in bradycardia by slowed conduction through AV node
  • Must be dosed in combination with glycopyrrolate, which is vagolytic and has a similar onset of effect.
  • Hypotension secondary to decreased in peripheral vascular resistance

Nausea and Vomiting

  • Conflicting studies with some reporting increased nausea and vomiting, some with antiemetic effect, and others showing no difference.
  • Meta-analysis by Tramer and Fuchs-Bader of 1100 patients showed incidence of vomiting in 17-33% and dose-dependent relationship between neostigmine and PONV

Pulmonary

  • Bronchospasm due to cholinergic effect
  • Hypoxia and increased secretions

Other:

· Miosis, increased GI secretions and motility, possible NMB at high doses

Side effects must be carefully balanced against the potential for residual weakness if patient does not have neuromuscular blockade antagonized

94%

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2020

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65%

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2019

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60%

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2017

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Author
James Dagenhart, MD