title: Reversal of pancuronium. Neuromuscular and cardiovascular effects of a mixture of neostigmine and glycopyrronium.
abstract: Moderate to deep (67-99% single twitch depression) pancuronium-induced neuromuscular blockade was antagonised with neostigmine (30 micrograms/kg, 60 micrograms/kg, or 80 micrograms/kg) in combination with glycopyrronium. Twenty-seven patients were reversed from 91%-99% twitch depression. Recovery of the first twitch of a train-of-four to 95% of control twitch took at least 20 minutes with neostigmine 30 micrograms/kg. The higher doses were significantly faster (60 micrograms/kg p less than 0.05, 80 micrograms/kg p less than 0.01) and took 15.8 and 14.8 minutes respectively. Reversal to a train of four ratio of 0.75 was not consistently achieved in under 30 minutes with any dose of neostigmine. Nineteen patients were antagonised from a 67%-80% depression of first twitch and in all but two recovery to 95% of control took under 10 minutes. To achieve a train of four ratio of 0.75 took less than 12.5 minutes except in three patients, two of whom, both given neostigmine 30 micrograms/kg, took longer than 20 minutes. Neostigmine 60 micrograms/kg produced as rapid a degree of antagonism as 80 micrograms/kg. Heart rates after reversal decreased gradually in all groups, although the decrease was initially greater in the low dose neostigmine (30 micrograms/kg) group. A fixed 5:1 ratio of neostigmine and glycopyrronium will usually antagonise a moderate (70%-80%) pancuronium block to a train of four of greater than 75% within 12.5 minutes if at least 60 micrograms/kg of neostigmine is administered. More than 30 minutes may be required for reversal whatever the dose of neostigmine, for antagonism from greater than 90% twitch depression.
authors.affiliation: Department of Anesthesia, Massachusetts General Hospital, Boston 02114.
authors.forename: D R
authors.initials: DR
authors.lastname: Goldhill
authors.forename: P B
authors.initials: PB
authors.lastname: Embree
authors.forename: H H
authors.initials: HH
authors.lastname: Ali
authors.forename: J J
authors.initials: JJ
authors.lastname: Savarese
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D004305:Dose-Response Relationship, Drug; D004338:Drug Combinations; D006024:Glycopyrrolate / Q000008:administration & dosage* / Q000494:pharmacology; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D008875:Middle Aged; D009119:Muscle Contraction / Q000187:drug effects; D009388:Neostigmine / Q000008:administration & dosage* / Q000494:pharmacology; D009469:Neuromuscular Junction / Q000187:drug effects; D010197:Pancuronium / Q000037:antagonists & inhibitors*; D011759:Pyrrolidines / Q000008:administration & dosage*; D011897:Random Allocation; D013997:Time Factors
chemical_list: D004338:Drug Combinations; D011759:Pyrrolidines; D009388:Neostigmine; D010197:Pancuronium; D006024:Glycopyrrolate