Neostigmine. By far the most commonly used anticholinesterase in anaesthesia is neostigmine. This is a water-soluble quaternary ammonium compound that combines reversibly with the esteratic site of the acetylcholinesterase enzyme rendering it inactive for about 30 minutes. Neostigmine is given as an intravenous injection at a dose of mg/kg (maximum 5mg), and should be administered with glycopyrronium mg/kg or atropine mg/kg. Neostigmine starts to take effect after approximately 2 minutes but has its maximal effect at 5-7 minutes. It is excreted unchanged by the kidney and has a half-life of about 45 minutes.
Understanding & Establishing Intraosseous Access
Intraosseous (IO) access is an alternative method to providing venous administration of drugs and fluids. Commonly used by the military and pre-hospital medics, intraosseous access has expanded its use to a variety of settings: in the emergency department, at cardiac arrests, in the paediatric population, and is gaining popularity in adult settings where intravenous access is challenging or time critical.
Length of Study: 50 min
On the other hand, we feel that endovascular therapies may be potentially more beneficial as a treatment option. Encouraging results have been reported with intra-arterial administration of papaverine and angioplasty of accessible spastic vessels. Timing of endovascular treatment is critically important to be effective. Intervention should be performed soon after it is apparent that a patient is progressing or failing to improve despite maximal medical therapy and before the onset of cerebral infarction. Indeed, cerebral angiography with the possibility of angiopalsty has become a routine part of our protocol in the management of symptomatic vasospasm. Figure 1 shows an example of a patient with symptomatic basilar artery vasospasm who made a significant recovery (from obtundation to following commands) after angioplasty.