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rocuronium are combined, resulting in the formation of a precipitate due to discordant differences in pH. 3 Glycopyrrolate, an anticholinergic agent, and rocuronium, a nondepolarizing neuromuscular blocking agent, are 2 drugs commonly used during general anesthesia although usually not concurrently as glycopyrrolate is used during reversal of rocuronium-induced paralysis. However, coadministration may occur if the anticholinergic effects of glycopyrrolate are indicated independent of rocuronium administration. If the patient's physiologic state (eg, excessive

. Due to their pharmacokinetic properties, the combination of neostigmine and glycopyrrolate or atropine and edrophonium is recommended. The purpose of the anticholinergic drug is to counteract the indirect muscarinic effects of the cholinesterase inhibiting drug, which when given alone can lead to significant bradycardia. We describe a case of heart block that occur following reversal of neuromuscular blockade with clinical doses of neostigmine and glycopyrrolate. We then summarize previous cases that have been reported in the literature and conclude by

, beta-adrenergic agonists, volatile anesthetics 5 (e.g., desflurane, halothane, isoflurane, and sevoflurane), and illicit drugs, including cocaine. 1 We describe the case of an 8-year-old boy with asymptomatic AIVR that manifested after neuromuscular blockade reversal with neostigmine and glycopyrrolate. Informed consent was obtained for publication of this case from the patient's legal guardian. CASE PRESENTATION Our 8-year-old male patient (height 146 cm; weight 61 kg; body mass index 28.6 kg/m 2 ) had a history of attention

% respectively), and occur less frequently than with neostigmine (8%) and succinylcholine (Sch; 9%). 5 Several case reports of bradycardia immediately following administration of sugammadex have been reported. 6 The FDA safety trials found a lower incidence of sugammadex-induced bradycardia (0.5%) when compared to neostigmine with glycopyrrolate (4.8%). Bradycardia resulting from sugammadex responds well to classical treatment with atropine. 5 The cause of bradycardia associated with sugammadex is unknown. Sugammadex is chemically inert and has no direct effects on

catheter to guide the nasal RAE through the right naris. There was no vomiting or esophageal regurgitation noted during intubation. The ECG, attached immediately after induction, demonstrated widened QRS segments suggestive of bundle branch block. Soon after intubation, a decrease in blood pressure from 118/87 mm Hg to 60/30 mm Hg occurred, associated with possible ST segment depression by ECG, but this was difficult to interpret in the presence of bundle branch block. The heart rate dropped to the low 70s. The patient was treated with glycopyrrolate, crystalloid

the fourth to first twitch. 3 The full dose of neostigmine is 0.05 mg/kg based on lean body weight. Accordingly, if there is minimal residual neuromuscular blockade, the neostigmine dose should be reduced by half of the appropriate dose. The surge in acetylcholine concentration precipitating unwanted parasympathetic vagal response requires concurrent administration of an antimuscarinic anticholinergic agent, namely, atropine 0.02 mg/kg or glycopyrrolate 0.004 mg/kg. A meta-analysis supports the preference for the coadministration of glycopyrrolate because of its

reduction of zygomatic arch fractures and manipulation of midface fractures. Asystole has been reported during downfracture of the maxilla during a Le Fort I osteotomy. Repositioning of the maxilla showed a return to sinus rhythm. Treatment with both atropine and glycopyrrolate allowed the downfracture to continue without further occurrence of a dysrhythmia. 2 The reflex has also been induced by a displaced zygomatic fracture and resolved when the fracture was reduced. 3 The case presented is a unique example of the trigeminovagal reflex where the afferent impulses are

≥80% of cases requiring preoperative IM sedation. Most respondents (96%) target a RASS score of −3, −4, or −5 after administering preoperative IM sedation. Similarly, 96% of respondents report achieving their anticipated level of sedation in >80% of cases. A small majority of respondents (51%) routinely administer anticholinergics with IM ketamine. When an anticholinergic is administered, IV glycopyrrolate is the most common drug and route of administration (24%). After administering preoperative IM sedation, most providers (74%) establish IV access next in their

necessary to prevent rapid increases in circulating acetylcholine, which may cause uterine contractions. 23 Glycopyrrolate Versus Atropine. Atropine, as opposed to glycopyrrolate, is the recommended anticholinergic agent co-administered with neostigmine for reversal. However, glycopyrrolate is a quaternary ionized amine that produced considerably less uptake and placental transfer compared with atropine. In a study of unanesthetized pregnant ewes, the administration of both atropine or glycopyrrolate yielded a 25% increase in