Utilizing calcium gluconate with low dose neostigmine to enhance neuromuscular recovery from non-depolarizing blockade: A prospective randomized control study

Ionized calcium has a pivotal role to play in neuromuscular transmission. Co-administration of calcium gluconate may allow for tapering the dose of neostigmine used for neuromuscular reversal, thus minimizing adverse effects associated with it while also reducing the chances of residual neuromuscular blockade (NMB). This study aimed to assess the effectiveness of calcium gluconate upon co-administration with neostigmine in enhancing rate of neuromuscular recovery and reducing the incidence of postoperative residual curarization. : This parallel group, double-blind randomized controlled study was conducted on 60 patients undergoing surgery at a tertiary care center. Patients in Group CN received 5 mg kg of 10% calcium gluconate with neostigmine while Group N received 5 ml 0.9% saline with neostigmine for reversal of NMB. Time from neostigmine administration to achieving a TOF ratio of ≥0.9 was taken as the primary outcome. Additional neostigmine requirement and symptoms of residual neuromuscular blockade (RNMB) in the post-anesthesia care unit (PACU) were considered as secondary outcomes. A significant difference was found in the meantime taken to achieve TOF ratio ≥0.9 after giving reversal, taking 5.43 ±2.12 mins in Group CN and 8.49 ±4.72 mins in Group N (p = 0.001). Although in Group N, 13.33% patients showed signs of RNMB in PACU versus 3.33% patients in Group CN. This difference was not found to be clinically significant (p=0.081). The findings of our study suggest that the administration of exogenous calcium may improve neuromuscular transmission even in normocalcemic patients. In conclusion, co-administration of calcium gluconate with low dose neostigmine helps in reducing neuromuscular recovery time in the early period of NMB reversal without incurring any significant disadvantages of administering higher doses of neostigmine.