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Overdosage with neuromuscular blocking agents may result in neuromuscular block beyond the time needed for surgery and anesthesia. The primary treatment is maintenance of a patent airway and controlled ventilation until recovery of normal neuromuscular function is assured. Once evidence of recovery from neuromuscular block is observed, further recovery may be facilitated by administration of an anticholinesterase agent (e.g., neostigmine, edrophonium) in conjunction with an appropriate anticholinergic agent (see Antagonism of Neuromuscular Block below).
Antagonism of Neuromuscular Block
ANTAGONISTS (SUCH AS NEOSTIGMINE) SHOULD NOT BE ADMINISTERED PRIOR TO THE DEMONSTRATION OF SOME SPONTANEOUS RECOVERY FROM NEUROMUSCULAR BLOCK. THE USE OF A NERVE STIMULATOR TO DOCUMENT RECOVERY AND ANTAGONISM OF NEUROMUSCULAR BLOCK IS RECOMMENDED. T4/T1 SHOULD BE > ZERO BEFORE ANTAGONISM IS ATTEMPTED.
In an analysis of patients in whom antagonism of neuromuscular block was evaluated following administration of single doses of neostigmine averaging 0.06 mg/kg (range: 0.05 to 0.075) administered at approximately 25% T1 spontaneous recovery during balanced anesthesia, 71% of patients exhibited T4/T1 ≥ 0.7 before monitoring was discontinued. For these patients, the mean time to T4/T1 ≥ 0.7 was 19 minutes (range: 7 to 55). As with other long-acting nondepolarizing neuromuscular blocking agents, the time for recovery of neuromuscular function following administration of neostigmine is dependent upon the level of residual neuromuscular block at the time of attempted reversal; longer recovery times than those cited above may be anticipated when neostigmine is administered at more profound levels of block (i.e., at < 25% T1 recovery).
Patients should be evaluated for adequate clinical evidence of antagonism, e.g., 5-second head lift, and grip strength. Ventilation must be supported until no longer required. As with other neuromuscular blocking agents, physicians should be alert to the possibility that the action of the drugs used to antagonize neuromuscular block may wear off before the effects of NUROMAX (doxacurium chloride) on the neuromuscular junction have declined sufficiently.
Antagonism may be delayed in the presence of debilitation, carcinomatosis, and the concomitant use of certain broad-spectrum antibiotics or anesthetic agents and other drugs which enhance neuromuscular block or separately cause respiratory depression (see PRECAUTIONS - DRUG INTERACTIONS). Under such circumstances the management is the same as that of prolonged neuromuscular block.
In clinical trials, a dose of 1 mg/kg edrophonium was not as effective as a dose of 0.06 mg/kg neostigmine in antagonizing moderate to deep levels of neuromuscular block (i.e., < 60% T1 recovery). Therefore, the use of 1 mg/kg edrophonium is not recommended for reversal from moderate to deep levels of block. The use of pyridostigmine has not been studied.
NUROMAX (doxacurium chloride) is contraindicated in patients with known hypersensitivity to the product and its components. NUROMAX (doxacurium chloride) is contraindicated for use in premature infants because the formulation contains benzyl alcohol. (See WARNINGS and PRECAUTIONS: Pediatric Use)This monograph has been modified to include the generic and brand name in many instances.
Last reviewed on RxList: 1/4/2011
Additional Nuromax Information
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