Neostigmine Reversal — FRCA Primary MCQ
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Reveal the answer and explanation
Correct answer: D — It follows advanced spontaneous recovery and requires quantitative monitoring to a TOF ratio greater than 0.9.
Explanation lettering: B = shown as A · A = shown as B · E = shown as C · C = shown as E
D is correct. Neostigmine reversibly inhibits acetylcholinesterase, increasing acetylcholine at the neuromuscular junction so that it competes with a non-depolarising blocker. Current guidance recommends advanced spontaneous recovery—quantitatively, a TOF ratio greater than 0.2—before neostigmine is given, followed by monitoring until the TOF ratio exceeds 0.9. Its efficacy has a ceiling, so deep block cannot be reversed reliably. Muscarinic effects include bradycardia, miosis, salivation, increased bronchial secretions and bronchospasm, making A incorrect. Neostigmine should be administered with an antimuscarinic such as glycopyrronium or atropine, excluding B. It does not bind the neuromuscular blocking drug directly, excluding C. Its effectiveness varies substantially with block depth, excluding E.
Reference: Fuchs-Buder T et al. Peri-operative management of neuromuscular blockade: a guideline from the European Society of Anaesthesiology and Intensive Care, Recommendation 8. European Journal of Anaesthesiology. 2023;40:82–94. https://pubmed.ncbi.nlm.nih.gov/36377554/