Reversal of neuromuscular blockade is sometimes used to assist in extubating a patient postoperatively. Generally, a train-of-four test is performed and if there are 1 or more twitches present, reversal is effected using neostigmine.
Neostigmine is an acetylcholinesterase inhibitor that functionally acts to increase acetylcholine in the neuromuscular junction.
Care must be taken when using this drug as the side effects include a vagal response causes bradycardia. To counteract the adverse effects of neuromuscular blockade glycopyrrolate or atropine is used.
Use of atropine can also have side effects, including emergence delirium and the medical mnenomic “mad, red, dry, hot, blind.”
For this reason, glycopyrrolate is strongly preferred by many experienced anesthesiologists and critical care physicians because it does not cross the blood brain barrier and is not associated with emergence delirium.