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. 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

Knowledge of reversal agents, or pharmacologic antagonists, is essential for all providers of sedation and general anesthesia. Reversal agents are defined as any drug used to counter the pharmacologic effects of another drug. 1 This article reviews common reversal agents used in contemporary sedation and anesthesia practice for dentistry, specifically flumazenil, naloxone, neostigmine, sugammadex, and phentolamine, and discusses their use in emergency management and routine practice. This article also reviews safety considerations and

, 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

Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear TD, Deshur MA, Benson J, Newmark RL, Maher CE. Neostigmine administration after spontaneous recovery to a train-of-four ratio of 0.9 to 1.0: a randomized controlled trial of the effect on neuromuscular and clinical recovery. Anesthesiology . 2018;128:27–37. When muscle relaxants are used to facilitate intubation, a significant amount of residual neuromuscular blockade remains when reversal drugs are not administered; however, routine reversal is not a universal practice. While most

SARS-CoV-2 is 2 to 3 times more contagious than influenza and may aerosolize and remain longer than influenza virus. 2 , 3 Krause M, McWilliams S, Bullard K, et al. Neostigmine versus sugammadex for reversal of neuromuscular blockade and effects on reintubation for respiratory failure or newly initiated noninvasive ventilation: an interrupted time series design. Anesth Analg . 2020;131:141–151. Pulmonary complications related to residual neuromuscular blockade are associated with postoperative morbidity and mortality. Using an interrupted

the most common complaints associated with general dentistry, a numb lip and tongue long after the dental procedure is completed. It will be exciting to see if this drug will eventually be classified as one of those miracle breakthrough drugs that change clinical practice. Another wonder drug on the immediate horizon, ORG 25969 (sugammadex), is a new type of reversal agent for nondepolarizing neuromuscular blocking drugs (NMBs) such as rocuronium. Unlike anticholinesterase agents such as neostigmine that permit the concentration of acetylcholine to build up

. This provides a similar time to good intubating conditions comparable to succinylcholine. Paralysis would, however, last considerably longer than succinylcholine—approximately 45 to 60 minutes, although reversal with neostigmine and glycopyrrolate could likely occur in less than 30 minutes. But with the availability of sugammadex when high doses (16 mg/kg) are used, full reversal occurs within approximately 3 minutes. If intubation is unsuccessful and a “cannot intubate/cannot ventilate” scenario occurs, this may be a shorter duration of action than succinylcholine