How to administer Neostigmine (neo) via intravenous (IV) push?

Neostigmine IV Push Administration

Administer neostigmine methylsulfate slowly by intravenous route over a period of at least 1 minute, using a dose of 0.03-0.07 mg/kg (maximum 5 mg total) based on the degree of neuromuscular blockade recovery. 1

Pre-Administration Requirements

Essential Monitoring Equipment

• Train-of-four (TOF) peripheral nerve stimulation devices are essential before administering neostigmine 1
• The first twitch response in the TOF must be at least 10% of baseline level (the response prior to neuromuscular blocking agent administration) before giving neostigmine 1

Anticholinergic Pre-treatment

• Administer atropine sulfate or glycopyrrolate prior to or concomitantly with neostigmine using a separate syringe 1
• In the presence of bradycardia, give the anticholinergic agent before neostigmine 1
• This pre-treatment is mandatory to lessen the risk of bradycardia, which is a known adverse effect of neostigmine 1

Dose Selection Algorithm

For Lower Doses (0.03 mg/kg)

• Use for neuromuscular blocking agents with shorter half-lives (e.g., rocuronium) 1
• Use when the first twitch response to TOF stimulus is substantially greater than 10% of baseline 1
• Use when a second twitch is present 1

For Higher Doses (0.07 mg/kg)

• Use for neuromuscular blocking agents with longer half-lives (e.g., vecuronium, pancuronium) 1
• Use when the first twitch response is relatively weak (not substantially greater than 10% of baseline) 1
• Use when more rapid recovery is needed 1

Administration Technique

Preparation Steps

• Visually inspect neostigmine methylsulfate injection for particulate matter and discoloration prior to administration 1
• Do not use if crystals or discoloration are present 1

IV Push Method

• Inject slowly by intravenous route over a period of at least 1 minute 1
• Available concentrations: 0.5 mg/mL (10 mL vials) or 1 mg/mL (10 mL vials) 1
• Maximum total dose is 0.07 mg/kg or 5 mg, whichever is less 1

Post-Administration Monitoring

Immediate Assessment

• A dose of 0.03-0.07 mg/kg will generally achieve a TOF twitch ratio of 90% (TOF0.9) within 10-20 minutes 1
• Continue TOF monitoring to evaluate the extent of recovery and determine if an additional dose is needed 1

Extended Monitoring

• Do not rely on TOF monitoring alone to determine adequacy of reversal -- patients must be monitored for their ability to adequately ventilate and maintain a patent airway following tracheal extubation 1
• Continue monitoring for a period that ensures full recovery based on the patient's medical condition and the pharmacokinetics of both neostigmine and the neuromuscular blocking agent used 1

Pediatric Considerations

• Pediatric patients (including neonates) require neostigmine doses similar to those for adult patients 1
• Follow the same adult guidelines for dose selection, administration rate, and monitoring 1

Critical Safety Warnings

High-Risk Patient Populations

• Use with caution in patients with coronary artery disease, cardiac arrhythmias, recent acute coronary syndrome, or myasthenia gravis 1
• These patients have increased risk of blood pressure and heart rate complications 1

Contraindications

• Known hypersensitivity to neostigmine (reactions include urticaria, angioedema, bronchospasm, bradycardia, anaphylaxis) 1
• Peritonitis or mechanical obstruction of the intestinal or urinary tract 1

Common Pitfalls

• Avoid large doses when neuromuscular blockade is minimal -- this can paradoxically produce neuromuscular dysfunction 1
• Have atropine and medications to treat anaphylaxis readily available due to the possibility of hypersensitivity reactions 1
• Neostigmine is rapidly eliminated with a slow disposition half-life ranging from 15.4-31.7 minutes, so effects typically peak between 7-15 minutes 2