Which reversal agents are used for nondepolarizing neuromuscular blocking agents and what coadministration reduces muscarinic effects?

• A. Reversal With Neostigmine Or Sugammadex; Coadminister Glycopyrrolate Or Atropine.
• B. Reversal With Edrophonium Or Pyridostigmine; Coadminister Epinephrine.
• C. Reversal With Flumazenil; No Anticholinergic Needed.
• D. Reversal With Naloxone; Coadminister Scopolamine.

Answer: (A)

Reversal of nondepolarizing neuromuscular blockers works by increasing acetylcholine at the neuromuscular junction so it can outcompete the blocker. The standard reversal agents are neostigmine (an acetylcholinesterase inhibitor) and sugammadex (which binds the NM blocker molecule directly). Because acetylcholinesterase inhibitors raise acetylcholine, they can overstimulate muscarinic receptors, causing unwanted effects like bradycardia and secretions, so an antimuscarinic is given at the same time. Glycopyrrolate or atropine are the common choices to blunt these muscarinic side effects. Sugammadex reverses certain steroidal blockers without increasing acetylcholine, so antimuscarinics aren’t typically needed with it, but when using acetylcholinesterase inhibitors, coadministration of glycopyrrolate or atropine is the standard approach.