Reversal of Residual Neuromuscular Block with Neostigmine at One to Four Hours After a Single Intubating Dose of Vecuronium

The purpose of this study was to measure the degree of residual neuromuscular block at different times after a single dose of vecuronium, and to evaluate the effectiveness of two different doses of neostigmine in antagonizing this residual block. Train-of-four (TOF) ratios were examined for up to 4 h after a single dose of vecuronium, 0.1 mg/kg, in 60 patients during nitrous oxide/isoflurane/fentanyl anesthesia. The effect of neostigmine, 40 micrograms/kg, was studied at 1,2,3, or 4 h. The effect of neostigmine, 20 micrograms/kg, was studied at 2 or 4 h after the vecuronium. Before neostigmine administration, the TOF ratio was less than 0.75 in 17 patients (including one patient at 4 h). Neostigmine produced an increase in TOF ratio in 52 patients and a decrease in 8. The TOF ratio decreased after neostigmine only, at 2,3, or 4 h after vecuronium, when the TOF ratio was > or = 0.9 and when neostigmine 40 micrograms/kg was administered. One patient, at 1 h, had a TOF ratio of 0.00 and this did not reach 0.75 until 57 min after neostigmine, 40 micrograms/kg. There was a high incidence (50%) of adverse cardiovascular effects after both doses of neostigmine. In making the decision as to whether neostigmine should be administered, the risk to the patient of residual neuromuscular block must be balanced against the adverse cardiovascular effects of the neostigmine.