After a careful rereading of the letter from Drs. Meyer and Eikermann, we remain confused as to their objection to our editorial.1  Their concern seems to be semantic in nature. In particular, they seem uneasy with the term routine. We think that they have ignored the basic message that we were attempting to make.

As stated in our editorial, neostigmine administration is not required once it has been determined that the train-of-four (TOF) ratio at the adductor pollicis has returned to a value of 0.90 or greater. This information can only be ascertained by using a quantitative neuromuscular monitor. Unfortunately, we suspect that the great majority of anesthesia practitioners still do not have access to these devices. What then is a clinician who only possesses a conventional peripheral nerve stimulator to do at the end of surgery when tactile or visual fade on TOF stimulation can no longer be detected?

It is our contention, in these circumstances, that the risk of respiratory complications from failure to reverse residual block far outweighs any theoretical adverse effects of neostigmine-induced “paradoxical paralysis.” We are unaware of any documented clinical morbidity associated with the use of low-dose neostigmine (less than or equal to 0.04 mg/kg) even when administered at TOF values of 0.90 or greater.

Competing Interests

Dr. Murphy has served as a consultant for Merck & Co. (Kenilworth, New Jersey). The other author declares no competing interests.


“To reverse or not to reverse?”: The answer is clear!