Clinical Recommendations

When antagonizing deep levels of neuromuscular blockade (≅10% recovery or one twitch in response to TOF stimulation), larger doses of anticholinesterases should be administered and adequate time allowed for recovery of neuromuscular function. The time required for recovery to a TOF ratio of 0.7 will be approximately 60 minutes for the long-acting neuromuscular blocking drugs and 30 minutes for the intermediate-acting ones. To antagonize lesser degrees of block, smaller doses of anticholinesterases may be administered, with additional anticholinesterase given if adequate recovery has not occurred in 10 minutes.

The maximum dose of neostigmine that should be administered is 70 µg/kg. Giving too much anticholinesterase to antagonize residual neuromuscular blockade may actually render patients weaker,^{[570] [616] [617]} probably because of the excess of acetylcholine at the neuromuscular junction that remains available to interact with the acetylcholine receptor.