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  1. Nov 25, '05 by devine1
    During my pediatric rotation I worked with a CRNA that routinely uses a combination of neostigmine and physostigmine for older children & adolescents. She calculates her normal neostigmine reversal dose but only gives 2/3 of it and the other 1/3 as physostigmine. For example, a 40kg pt may require 2.4mg of neostigmine but she only gives 1.6mg while giving the other 0.8mg as physostigmine. She states that these patients wake up "smoother" than those receiving just neostigmine but has no solid reasoning for doing so. Apparently she learned this from her preceptor many years ago. I understand that physostigmine has a tertiary amino group that passes the blood brain barrier but this patient population doesn't necessarily receive any anticholinergic that passes the barrier (e.g. Atropine).

    Does anybody have any insight on this?
    Thanks.

  2. 13 Comments so far...

  3. Nov 26, '05 by gotosleep
    doesn't make any sense...another example of voodoo anesthesia. sad.
  4. Nov 26, '05 by Pete495
    If it's comfortable for the patient, does it have to be sad?

    just playing devil's advocate. I realize it's not evidence based medicine.
  5. Nov 27, '05 by jwk
    Bogus all around. Physostigmine is not indicated for reversal of NMB. Any chance you're thinking of pyridostigmine, which is a pretty old drug we used to use eons ago?

    And if you have "no solid reasoning for doing so", why the hell would you give it, or anything else for that matter? It has nothing to do with being "comfortable for the patient" (where did that come from?)
  6. Nov 27, '05 by piper77
    Hate to disagree with you, jwk, but physostigmine is, of course, a cholinesterase inhibitor, and has LONG been used as a reversal agent - don't know where you came up with idea that it has no indications as one. That being said....I certainly don't see it being used much these days at all, and have not seen any combinations as described above. Devine....sounds like an interesting mini-research project......My guess is that you will find most clinicians don't use it at all anymore. Good luck!
  7. Nov 27, '05 by jwk
    Quote from piper77
    Hate to disagree with you, jwk, but physostigmine is, of course, a cholinesterase inhibitor, and has LONG been used as a reversal agent - don't know where you came up with idea that it has no indications as one. That being said....I certainly don't see it being used much these days at all, and have not seen any combinations as described above. Devine....sounds like an interesting mini-research project......My guess is that you will find most clinicians don't use it at all anymore. Good luck!
    OK, an ACH inhibitor it is, but in 25 years, I've never seen it used for reversing NMB's. I've got a few old-fashioned tricks up my sleeve as well, but this isn't one of them.

    However, I'll stand by my statement that if you have "no solid reasoning for doing so" then you shouldn't be giving any drug or treatment. If you don't have a reason for, or understand why you're doing what you're doing, then don't do it. And just doing it because someone else told you it was neat to do years ago? Not a good reason either.
  8. Nov 27, '05 by piper77
    Quote from jwk
    OK, an ACH inhibitor it is, but in 25 years, I've never seen it used for reversing NMB's. I've got a few old-fashioned tricks up my sleeve as well, but this isn't one of them.

    However, I'll stand by my statement that if you have "no solid reasoning for doing so" then you shouldn't be giving any drug or treatment. If you don't have a reason for, or understand why you're doing what you're doing, then don't do it. And just doing it because someone else told you it was neat to do years ago? Not a good reason either.
    Well, jwk...jes take a peek at any good anesthesia reference, and there you will find it. Funny what a good read will do.
    Could be me, but you sound a little defensive. I think anybody would agree that good practice should have solid reasoning behind it. Devine was just asking a question....and that is exactly what students should be doing, and encouraged to do. Keep asking, Devine!
  9. Nov 29, '05 by devine1
    Thanks for the replies! The use of physostigmine isn't my choice of routine neuromuscular blockade reversal and I've never chosen to give it over others.
    The CRNA that shared this technique with me certainly has her reasoning for using it, but it is my intention to find out why it may or may not work. Obviously I don't just reach in the drug tray and give drugs without knowing all appropriate indications; but, if there are "tricks" that people have passed down over the years, I don't mind investigating one's reasoning before accepting it.
  10. Dec 3, '05 by mwbeah
    Quote from devine1
    Thanks for the replies! The use of physostigmine isn't my choice of routine neuromuscular blockade reversal and I've never chosen to give it over others.
    The CRNA that shared this technique with me certainly has her reasoning for using it, but it is my intention to find out why it may or may not work. Obviously I don't just reach in the drug tray and give drugs without knowing all appropriate indications; but, if there are "tricks" that people have passed down over the years, I don't mind investigating one's reasoning before accepting it.
    Is the practioner using atropine or robinul in the mix? That might explain the physostigmine.

    Mike
  11. Dec 3, '05 by mwbeah
    Quote from devine1
    this patient population doesn't necessarily receive any anticholinergic that passes the barrier (e.g. Atropine).

    Does anybody have any insight on this?
    Thanks.
    What is the dose of atropine?