Use Of Neostigmine Research Articles

Non-narcotic adjuvants may improve the duration and quality of analgesia after knee arthroscopy: a brief review

We have evaluated randomized controlled trials of the administration of clonidine, neostigmine, steroids and non-steroidal anti-inflammatory agents intra-articularly as adjuvants to local anesthetic drugs after arthroscopic knee surgery. Twenty-five studies were reviewed using specific inclusion criteria and, accordingly, included in the final assessment. These studies were assessed for pain scores, total analgesic consumption and time to first analgesic request to determine a possible peripheral effect, as opposed to possible systemic effects of an adjuvant administered intra-articularly. A total of 16 studies, met the inclusion criteria. These studies considered the use of non-steroidal anti-inflammatory drugs, steroids, neostigmine and clonidine. Ketorolac was used in four studies (for a total of 230 patients) and showed a significant improvement in analgesia. Clonidine has shown considerable analgesic effect, with minimal adverse effects. All seven studies assessed in this review were supportive (a total of 424 patients). Furthermore the addition of clonidine to bupivacaine or morphine was found to increase duration and quality of postoperative analgesia. Current evidence indicates that a variety of agents have synergistic effects when added to local anesthetics and there is evidence that the improvement in analgesia is, at least partially, through a local rather than a central mechanism. The results of this review suggest that clonidine and ketorolac, when administered intra-articulary after arthroscopic knee surgery, may reduce postoperative pain.

The efficacy of intra-articular ketamine for postoperative analgesia in outpatient arthroscopic surgery

Purpose The purpose of this study was to compare the postoperative analgesic effects of intra-articularly administered ketamine, neostigmine, and bupivacaine after outpatient arthroscopic surgery. Type of study Prospective, randomized, double-blind, clinical study. Methods In this study, 60 patients undergoing arthroscopic surgery other than ligament reconstruction were evaluated for postoperative pain. Ketamine, neostigmine, and bupivacaine were administered intra-articularly. The period of effective analgesia, recorded in minutes, was measured between time 0 and first usage of patient-controlled anesthesia (PCA) by the patients. The visual analog scale (VAS) was used to describe the pain level of the patient. Results VAS values were lower for the 3 medication groups compared with the placebo at rest and 90° knee flexion. Intra-articular administration of 0.5 mg/kg ketamine provided longer duration of analgesia as defined by the first PCA use time ( P < .05). The total amount of pethidine and analgesia time were longer for the 3 medication groups. Conclusions Our basic finding was reduction in postoperative pain and consumption of adequate analgesic drugs with intra-articular ketamine, bupivacaine, or neostigmine use. We have not seen any psychomimetic side effects, particularly as seen with higher doses or systemic use. This study may conclude that intra-articular administration of ketamine provides long-lasting and effective analgesia, similar to neostigmine but less effective than bupivacaine after knee arthroscopy without any adverse effects. Level of evidence Level I.

Colonic anastomotic disruption in the immediate postoperative period

Muscle relaxation is administered to patients undergoing laparotomy for colonic surgery. At the end of the procedure, relaxation needs to be reversed to facilitate extubation. This may be achieved by administering anticholinesterases such as neostigmine. We present a case of colonic anastomotic dehiscence in the immediate postoperative period following the use of neostigmine to reverse intra-operative muscle relaxation. Neostigmine is frequently used to reverse muscle relaxation at the end of colonic surgery. However, the drug should be used with caution as it has been implicated as a cause of early anastomotic disruption.

Assessment of predictors of response to neostigmine for acute colonic pseudo-obstruction

OBJECTIVE: Acute colonic pseudoobstruction (ACPO) most commonly develops after surgery, with narcotic administration, or in association with severe illness. Most cases resolve with conservative management. Colonoscopic decompression may be required in patients failing to respond to conservative treatment. Neostigmine has been proposed as an effective treatment for ACPO as an alternative to colonoscopic decompression. We sought to identify factors associated with spontaneous resolution of ACPO and to identify variables associated with a response to i.v. administration of neostigmine for the treatment of ACPO. METHODS: Retrospective analysis of Mayo Clinic’s diagnostic index revealed all patients who developed ACPO between July, 1999 and September, 2001 at the Mayo Clinic Medical Center. We separately analyzed those patients who did not resolve ACPO with conservative management and to whom i.v. neostigmine was administered. Patient records were abstracted for demographic data, etiology of ACPO, management, and response to treatment. RESULTS: A total of 151 patients were identified with ACPO between July, 1999 and September, 2001; 117 patients (77%) had spontaneous resolution of symptoms. Of the 34 “nonresolvers,” 18 patients received neostigmine, whereas 16 did not receive neostigmine. Of those 16 patients, 11 required colonoscopic decompression, two underwent surgery, and three died of underlying illness. “Spontaneous resolvers” were less likely to be taking narcotics (59% vs 74%, p = 0.08). Of the 16 nonresolvers who did not receive neostigmine, only one had a contraindication to neostigmine use. Of the 18 patients that who received neostigmine, 16 patients (89%) had prompt evacuation (<30 min) of flatus or stool. Sustained clinical response to neostigmine was noted in 11 of 18 (61%); the remaining seven patients (39%) required colonoscopic decompression or surgery for recurrent or persistent colonic dilation. Neostigmine-responders were more likely to be older (mean age, 76 yr vs 54 yr, p = 0.03), than nonresponders. Preneostigmine cecal diameter did not differ significantly between responders (median, 12 cm) and nonresponders (median, 13 cm), p = 0.9. Median time to resolution of ACPO in spontaneous resolvers was 4 days compared to 2 days in patients responding to neostigmine; p = 0.038. CONCLUSIONS: Most patients with ACPO respond to conservative treatment. Female gender and older age are associated with a response to neostigmine in those patients who do not respond to conservative management. Neostigmine appears to be under-used in patients with ACPO who do not have a true contraindication to its use.

Assessment of predictors of response to neostigmine for acute colonic pseudo-obstruction.

Acute colonic pseudoobstruction (ACPO) most commonly develops after surgery, with narcotic administration, or in association with severe illness. Most cases resolve with conservative management. Colonoscopic decompression may be required in patients failing to respond to conservative treatment. Neostigmine has been proposed as an effective treatment for ACPO as an alternative to colonoscopic decompression. We sought to identify factors associated with spontaneous resolution of ACPO and to identify variables associated with a response to i.v. administration of neostigmine for the treatment of ACPO. Retrospective analysis of Mayo Clinic's diagnostic index revealed all patients who developed ACPO between July, 1999 and September, 2001 at the Mayo Clinic Medical Center. We separately analyzed those patients who did not resolve ACPO with conservative management and to whom i.v. neostigmine was administered. Patient records were abstracted for demographic data, etiology of ACPO, management, and response to treatment. A total of 151 patients were identified with ACPO between July, 1999 and September, 2001; 117 patients (77%) had spontaneous resolution of symptoms. Of the 34 "nonresolvers," 18 patients received neostigmine, whereas 16 did not receive neostigmine. Of those 16 patients, 11 required colonoscopic decompression, two underwent surgery, and three died of underlying illness. "Spontaneous resolvers" were less likely to be taking narcotics (59% vs 74%, p = 0.08). Of the 16 nonresolvers who did not receive neostigmine, only one had a contraindication to neostigmine use. Of the 18 patients that who received neostigmine, 16 patients (89%) had prompt evacuation (<30 min) of flatus or stool. Sustained clinical response to neostigmine was noted in 11 of 18 (61%); the remaining seven patients (39%) required colonoscopic decompression or surgery for recurrent or persistent colonic dilation. Neostigmine-responders were more likely to be older (mean age, 76 yr vs 54 yr, p = 0.03), than nonresponders. Preneostigmine cecal diameter did not differ significantly between responders (median, 12 cm) and nonresponders (median, 13 cm), p = 0.9. Median time to resolution of ACPO in spontaneous resolvers was 4 days compared to 2 days in patients responding to neostigmine; p = 0.038. Most patients with ACPO respond to conservative treatment. Female gender and older age are associated with a response to neostigmine in those patients who do not respond to conservative management. Neostigmine appears to be under-used in patients with ACPO who do not have a true contraindication to its use.

Successful Use of Neostigmine in A Patient With Refractory Distal Intestinal Obstruction Syndrome

Successful Use of Neostigmine in A Patient With Refractory Distal Intestinal Obstruction Syndrome

A Comparison of the Effects on Inducing Hypotension and Bradycardia between Esmolol Infusion Alone and Concomitant Use of Neostigmine for MIDCAB Anesthesia

A Comparison of the Effects on Inducing Hypotension and Bradycardia between Esmolol Infusion Alone and Concomitant Use of Neostigmine for MIDCAB Anesthesia

The novel analgesic neostigmine and the morning after: Nothing more than sedation, nausea and vomiting?

Abstract Since the introduction of opioids as spinally active analgesics into the field of pain research and management, the spinal cord and the peripheral nervous system have been explored for numerous different physiological and pharmacological pain modulating systems. Thereby the use of cholinergic agonists and acetylcholinesterase-inhibitors was investigated with respect to their specific antinociceptive activity, any potential side effects and also with regard to any potential toxicity after their spinal administration. Besides analgesia, spinal cholinergic agonists will also result in motor weakness. Neostigmine, a clinically well-known acetylcholine (ACh)-esterase inhibitor, was found however to result in dose-dependent, potent analgesia after spinal and peripheral administration in preclinical and clinical trials. The clinical studies exploiting spinal or epidural administration of neostigmine revealed an analgesic effect for neostigmine 50–100 μg comparable to that of spinally applied morphine. Neostigmine lacks any neurotoxicity after intrathecal injection, although its spinal and epidural use might be limited by another side effect — the high incidence of nausea and vomiting. Based on the findings of a peripheral analgesic action of opioids, neostigmine's peripheral analgesic effects were also demonstrated in acute pain states. Here it is shown that postoperative analgesia can be accomplished by intra-articular neostigmine and by co-delivery of neostigmine with mepivacaine in axillary plexus blockade. However, further studies on the underlying mechanisms of peripheral antinociception are warranted before the routine clinical use of neostigmine as a peripheral acting analgesic can be recommended. In conclusion, due to its potential side effects, the use of the otherwise very effective spinal analgesic neostigmine will be limited to certain specific pain states or as a co-drug with other analgesics.

Discharge criteria and complications after ambulatory surgery.

I n recent years, the emphasis in providing surgical services has undergone remarkable change. Previously, patients undergoing surgical procedures remained in a hospital for many days after the operation. In 1994, 66% of all elective operations in the United States were performed on an outpatient basis (1). More complex ambulatory procedures are being performed on sicker patients (2). With the increased emphasis on early discharge after surgery and anesthesia, it is important to identify criteria that can be used to determine when patients can safely go home under the care of a friend or relative. In this article, we review current knowledge regarding the assessment of home-readiness after ambulatory surgery and discuss potential complications and appropriate treatment regimens.

Discharge Criteria and Complications After Ambulatory Surgery

Discharge Criteria and Complications After Ambulatory Surgery

Other Ways to Stimulate Postoperative Bowel Function

In Response: We are grateful for Dr. Herschman's interest in our study. Neostigmine in controlled studies has not shown consistent efficacy in shortening the course of postoperative ileus [1]. Additionally, because it can cause powerful contractures of the intestine, some surgeons are concerned about its use immediately after a colonic anastomosis [2]. As a long-acting anticholinesterase inhibitor, neostigmine can have a profound effect on heart rate, salivation, nausea [3], and reactive airways. Patients receiving this drug require postadministration monitoring. The cost of administrating IV neostigmine is therefore considerable if one includes the time required to observe the patient after the drug is given. Assuming that IV neostigmine is clinically effective in decreasing the duration of postoperative ileus, lidocaine still has other advantages that make it a better pharmacologic agent. These include: no additional monitoring (the drug is given in the operating room and postanesthesia care unit, where appropriate monitoring is routine), a low cost, very few patient contraindications, and-most significantly-a reduction in postoperative pain. We believe that the benefits of perioperative lidocaine warrant its use with patients undergoing radical retropubic prostatectomy, and possibly other surgeries where postoperative ileus is anticipated. Dr. Herschman's use of neostigmine is a treatment option for ileus, whereas IV lidocaine is a preemptive therapy aimed at attenuating the duration of ileus. The differences in indication, monitoring requirements, patient selection, and effects on postoperative pain between lidocaine and neostigmine would make any comparative study difficult to interpret clinically. Scott Groudine, MD Philip D. Lumb, MBBS Department of Anesthesiology; Albany Medical Center; Albany, NY 12208

The use of neostigmine to decrease the heart rate in a patient undergoing minimally invasive coronary artery bypass surgery

The use of neostigmine to decrease the heart rate in a patient undergoing minimally invasive coronary artery bypass surgery

Anesthetic and surgical complications in 219 cases of myotonic dystrophy.

The objective of this study was to assess the frequency, type, and severity of perioperative complications after a first surgery under general anesthesia in patients with myotonic dystrophy (DM) and to measure the association with suspected risk factors. Numerous cases of perioperative complications in DM patients have been reported. Hazards have been associated with the use of thiopentone, suxamethonium, neostigmine, and halothane. A retrospective study of perioperative complications was conducted for 219 DM patients who had their first surgery under general anesthesia at the Chicoutimi Hospital. The overall frequency of complications was 8.2% (18 of 219). Most complications (16 of 18) were pulmonary, including five patients with acute ventilatory failure necessitating ventilatory support, four patients with atelectasis, and three patients with pneumonia. Using multivariate analysis, we found that the risk of perioperative pulmonary complications (PPC) was significantly higher after an upper abdominal surgery (odds ratio (OR), 24.4; 95% CI, 4.0 to 149.3) and for patients with a severe muscular disability, as assessed by the presence of proximal limb weakness (OR, 14.1; 95% CI, 1.5 to 134.4). The likelihood of PPC was not related to any specific anesthetic drug. Because of the increased risk of PPC, careful monitoring during the early postoperative period, protection of upper airways, chest physiotherapy, and incentive spirometry are mandatory in all symptomatic DM patients, particularly those with a severe muscular disability or those who have undergone an upper abdominal surgery.

Markedly Prolonged Paralysis After Mivacurium in a Patient Apparently Heterozygous for the Atypical and Usual Pseudocholinesterase Alleles by Conventional Biochemical Testing

Markedly Prolonged Paralysis After Mivacurium in a Patient Apparently Heterozygous for the Atypical and Usual Pseudocholinesterase Alleles by Conventional Biochemical Testing

Is recovery of neuromuscular transmission complete after the use of neostigmine to antagonize block produced by rocuronium, vecuronium, atracurium and pancuronium?

To test if recovery of neuromuscular transmission is complete after the use of neostigmine under standardized conditions, we have measured adductor pollicis mechanical activity in response to 0.1 Hz (twitch height), train-of-four (TOF) and 100 Hz (RF 100 Hz) ulnar nerve stimulations. We studied 56 adult anaesthetized (thiopentone, fentanyl, nitrous oxide in oxygen) patients, allocated randomly to one of four groups (n = 14) to receive rocuronium (group Roc), vecuronium (group Vec), atracurium (group Atr) or pancuronium (group Pan). Recovery of neuromuscular transmission was studied for 15 min after neostigmine 40 micrograms kg-1 was given at 25% recovery of twitch height. Fifteen minutes after antagonism, the TOF ratio was 0.91 (SEM 0.01), 0.88 (0.02) and 0.92 (0.01) (ns), and RF 100 Hz was 0.78 (0.01), 0.79 (0.02) and 0.78 (0.01) (ns) respectively, in patients in groups Roc, Vec and Atr, respectively. In patients in group Pan, TOF ratio and RF 100 Hz were only 0.76 (0.01) and 0.33 (0.04) respectively (P < 0.01, one-way analysis of variance, Duncan's multiple classification range tests). In contrast with pancuronium, antagonism of rocuronium-, vecuronium- and atracurium-induced neuromuscular blocks produced a similar high degree of recovery of neuromuscular transmission.

28th Annual Meeting of the Society for Obstetric Anesthesia and Perinatology

28th Annual Meeting of the Society for Obstetric Anesthesia and Perinatology

Effect of Antagonism of Mivacurium-Induced Neuromuscular Block on Postoperative Emesis in Children

The routine use of cholinesterase inhibitors to antagonize residual neuromuscular block may be associated with increased postoperative emesis.Rapid spontaneous recovery from mivacurium may obviate the need for these drugs. In this randomized, double-blind, placebo-controlled study of 113 healthy children who had received mivacurium as part of a standardized anesthetic regimen, we compared the incidence of postoperative complications after spontaneous recovery and after the use of neostigmine-glycopyrrolate or edrophonium-atropine. The anesthetic regimen consisted of halothane, nitrous oxide, fentanyl, 2 micro gram/kg intravenous (IV), mivacurium in an initial dose of 0.2 mg/kg, followed by an infusion, adjusted to maintain >or=to1 evoked contraction response to a supramaximum train-of-four stimulus. At the end of the procedure, patients received by random assignment one of three drug combinations: 1) neostigmine 70 micro gram/kg + glycopyrrolate 10 micro gram/kg, IV, 2) edrophonium 1 mg/kg + atropine 10 micro gram/kg, IV, and 3) saline. The trachea was extubated when evoked responses to peripheral nerve stimulation and clinical signs of adequate neuromuscular recovery were present. Postoperative pain was treated with morphine and emesis with metoclopramide. There were no significant differences between the three groups with respect to age, surgery, intraoperative fentanyl, and mivacurium use, time from the end of surgery to tracheal extubation, postanesthesia care unit (PACU) arrival and discharge, or in postoperative oxygen saturation values and analgesic requirements. Compared to the placebo group, emesis occurred more often in the PACU in patients receiving the neostigmine-glycopyrrolate combination, but not after edrophonium-atropine. However, after discharge from the PACU, emesis rates were similar in the three study groups. We conclude that spontaneous recovery or reversal with edrophonium from a moderate degree of mivacurium-induced block may offer advantages over the use of neostigmine, without increasing time to PACU arrival. (Anesth Analg 1995;80:713-17)

Use of neostigmine in meteorism of the horse

Use of neostigmine in meteorism of the horse

Neostigmine or β-blockers? A pharmacologic conundrum

T HE CONTROL OF heart rate and rhythm under anesthesia may present difficulty in the presence of coincident valvular heart disease, poor ventricular function, or pressure-dependent organ perfusion; particularly when currently available antiarrhythmic drugs, such as betablockers and calcium antagonists, may have undesirable negative inotropic or vasodilator effects in addition to their desired chronotropic effects. Neostigmine is used routinely in anesthetic practice as an anticholinesterase to provide “reversal” of nicotinic cholinergic blockade at the neuromuscular junction. Concurrent administration of anticholinergic drugs, (atropine or glycopyrronium) is usual to prevent troublesome muscarinic side effects, such as bradycardia. Both neostigmine and edrophonium have been used by bolus injection and by continuous infusion, in the case of edrophonium, to treat supraventricular arrhythmias in awake patients, making specific use of such side effects.‘” The use of low-dose neostigmine as a negative chronotrope in an anesthetized patient is described, in whom conventional agents were thought to be more likely to cause undesirable effects than the deliberate use of the muscarinic side effects of neostigmine. left axillo-bifemoral conduit was established to provide distal perfusion. A total of 12 L of blood was lost. Warmed whole blood, crystalloid and colloid solutions were used to maintain filling pressures as nearly as possible at preincision levels. During siting of the axillo-bifemoral graft, the heart rate rose from 85 to 112 beats/min (sinus rhythm), the blood pressure from 190/100 to 2101120 mmHg, and the pulmonary artery diastolic pressure from 21 to 31 mmHg. A further dose of fentanyl(6 kg/kg) was administered, with no effect on heart rate. It is believed that, in the presence of aortic stenosis and poor ventricular function, associated with massive blood transfusion, the rise in heart rate was leading to cardiac decompensation. The heart rate had to be lowered with minimum reduction of contractility and peripheral resistance. Accordingly, vecuronium, 8 mg, was given to maintain nicotinic blockade, followed by neostigmine in 100 kg aliquots to a total of 400 pg. Over the next 5 minutes reductions occurred in the heart rate from 112 to 65 beats/min, in the PA diastolic pressure from 31 mmHg to 22 mmHg, and in the blood pressure from 2101120 to 1701110 mmHg. Subsequently, anesthesia and surgery were uneventful and the patient was returned to intensive care where she was ventilated postoperatively for 36 hours. The patient left the hospital 15 days later, with no additional changes in her ECG to suggest any acquired myocardial damage.

Use of low-dose neostigmine intravenously in the treatment of supraventricular tachycardia: An immediate bradycardic effect

Neostigmine was first used 50 years ago to treat sinus tachycardia and paroxysmal auricular tachycardia. Then there were reports of successful treatment by neostigmine of other forms of supraventricular tachycardias. However, reports of sudden death using neostigmine for reversal of neuromuscular blockade at the end of an operation, which were not properly treated with atropine abandoned the use of neostigmine as an antiarrhythmic drug. Low-dose neostigmine intravenously was used in the treatment of supraventricular tachycardia in three patients described herein. It gave an immediate bradycardic effect in all three patients. The use of a low-dose neostigmine intravenously for an immediate treatment of supraventricular tachycardia is a novel suggestion. It has to be further evaluated and compared to the conventional drugs used like digoxin, verapamil, propranolol or esmolol.