Acetylcholinesterase Inhibitors

► Hypotension
► Nausea/ Vomiting
Authors: Sunny Fong Reviewers: Joseph Tropiano Billy Sun Melinda Davis, MD
Quick Facts
Primary indication in the OR = Used as a reversal agent against non-depolarizing neuromuscular blockers post-surgery
Route of Administration = IV
Metabolism & Excretion = hepatic clearance and renal excretion
See Anticholinerqics slide for reversal of parasympathetic effects due to acetylcholinesterase inhibitors
ACh — Acetylcholine NDNMBs — Non-depolarizing neuromuscular blockers
Acetylcholinesterase Inhibitors E.g. Neostigmine, Pyridostigmine, Physostigmine
4, Breakdown of ACh in neuromuscular junctions

ACh available to compete with NDNMBs to bind to post-synaptic nicotinic receptors on muscles
Reversible enzymatic inhibition of acetylcholinesterase
ACh available to compete with NDNMBs to bind to pre-synaptic nicotinic receptors on neurons

Normal neuromuscular junction function re-established
1` Positive feedback for continued ACh release
Reversal of neuromuscular block
Excess dose leads to depolarizing block of the nicotinic receptors

Flaccid skeletal muscle paralysis
Respiratory paralysis & failure
4, Breakdown of ACh in rest of body
1` Stimulation of muscarinic receptors various organ systems
Muscarinic (parasympathetic) effects
► Bradycardia
Bronchial Secretions
Legend: Pathophysiology Mechanism Sign/Symptom/Lab Finding Complications I Published March 3, 2018 on
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