Management of Neostigmine-Induced Bradycardia

Identification of High-Risk Patients and Symptoms

The American Heart Association recommends holding neostigmine immediately if the patient develops acutely altered mental status, ischemic chest discomfort, acute heart failure, or hypotension, as these are signs of symptomatic bradycardia 1
Patients with coronary artery disease, cardiac arrhythmias, or recent acute coronary syndrome should be considered high-risk and neostigmine should be held at higher heart rates 1
The American College of Cardiology suggests that other signs of shock, such as low blood pressure, are also indications to hold neostigmine 3, 4

The American Heart Association recommends administering atropine 0.5 mg IV every 3-5 minutes to a maximum total dose of 3 mg as first-line treatment for neostigmine-induced bradycardia 4, 1
Doses of atropine <0.5 mg may paradoxically worsen bradycardia, according to the American College of Cardiology 4
If bradycardia persists despite atropine, consider β-adrenergic agonists with rate-accelerating effects, such as dopamine (2-10 μg/kg/min) or epinephrine (2-10 μg/min), as recommended by the American Heart Association 3, 2
Transcutaneous pacing (TCP) should be considered if medications fail, according to the American College of Cardiology 3, 4

Cardiac transplant patients may be particularly sensitive to neostigmine-induced bradycardia, and the heart rate response to atropine may be blunted due to denervation, as noted by the American Heart Association 4
Avoid relying solely on atropine in patients with type II second-degree or third-degree AV block, as these bradyarrhythmias may not respond to cholinergic reversal, according to the American College of Cardiology 4
Do not delay implementation of external pacing for patients with poor perfusion while waiting for atropine to take effect, as recommended by the American Heart Association 4