***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Neostigmine antagonism after suxamethonium followed by mivacurium chloride bolus and infusion was studied . Thirty ASA group I or II patients were given mivacurium 0.15 mg/kg followed by infusion during nitrous oxide-enflurane-pethidine anaesthesia . Train of four ( TOF ) stimuli were applied to the ulnar nerve at the wrist and TOF twitch height and ratio measured by TOF-GUARD nerve stimulator . Mivacurium infusion was titrated to give a 90 % block of first twitch height . Patients were r and omized into two groups . Group I patients recovered from the mivacurium block spontaneously while Group II patients were given neostigmine 0.05 mg/kg and atropine 0.02 mg/kg . Time to reach train of four ratio ( TOFR ) of 25 % , 50 % and 70 % were measured . This study demonstrated a mean infusion rate of 5.1±1.8 μg/kg/min to maintain a 90 % neuromuscular block . In the spontaneous recovery group , time to reach TOFR of 25 % , 50 % and 70 % were 9.3±2.7 min , 13.5±3.0 min and 16.7±3.0 min respectively while the corresponding times in the neostigmine group were 5.2±1.7 min , 10.9±2.2 min and 16.1±7.4 min respectively . There were significant differences in the time taken to TOFR of 25 % ( P<0.0001 ) and 50 % ( P<0.05 ) but no difference in the time taken for TOFR to return to 70 % . We concluded that mivacurium is suitable for use in caesarean section despite a decrease in plasma cholinesterase activity . Neostigmine antagonism is not required as a routine BACKGROUND The authors examined the plasma concentrations of the isomers of mivacurium and its pharmacodynamics during spontaeous and neostigmine-facilitated recovery after a mivacurium infusion . METHODS Sixteen patients receiving nitrous oxide-opioid anesthesia  received 0.25 mg/kg mivacurium . Patient response to neuromuscular stimulation was determined using a mechanomyograph Once T1 had recovered to 25 % of its baseline height , a mivacurium infusion was begun and adjusted to maintain 95 - 99 % neuromuscular block . The infusion was discontinued after 90 min and muscle strength allowed to recover either spontaneously or after neostigmine/glycopyrrolate ( 0.05/0.01 mg/kg ) . Plasma concentrations of the isomers of mivacurium  after discontinuation of the infusion were determined using an HPLC assay . Differences between the groups were determined using a one-way analysis of variance with a Bonferroni-corrected t test or Student t test as appropriate . P < or = 0.05 was considered significant . RESULTS Differences in the times for recovery to a train-of-four ratio of 70 % did not achieve statistical significance ( mean+/-SD , 13.3+/-6.0 vs. 16.3+/-2.5 min for the neostigmine and spontaneous groups , respectively ) . Plasma cholinesterase activity decreased significantly from baseline values after administration of neostigmine ( 5.88+/-0.21 vs. 0.43+/-0.04 U/ml plasma ) . Plasma concentrations of the trans-trans isomer were significantly greater in the neostigmine group than in the spontaneous recovery group 5 , 6 , 8 , and 10 min after discontinuation of the infusion . Differences in the plasma concentration of the cis-trans isomer did not achieve statistical significance . CONCLUSIONS Although administration of neostigmine decreased plasma cholinesterase activity and caused the trans-trans isomer to remain in the plasma at higher concentration , it did not delay recovery from mivacurium-induced block Background : Incomplete recovery from neuromuscular blockade in the postanesthesia care unit ( PACU ) may contribute to adverse postoperative respiratory events . This study determined the incidence and degree of residual neuromuscular blockade in patients r and omized to conventional qualitative train-of-four ( TOF ) monitoring or quantitative acceleromyographic monitoring .  The incidence of adverse respiratory events in the PACU was also evaluated . Methods : One hundred eighty-five patients were r and omized to intraoperative acceleromyographic monitoring ( acceleromyography group ) or qualitative TOF monitoring ( TOF group ) . Anesthetic management was st and ardized . TOF patients were extubated when st and ard criteria were met and no fade was observed during TOF stimulation . Acceleromyography patients had a TOF ratio of greater than 0.80 as an additional extubation criterion . Upon arrival in the PACU , TOF ratios of both groups were measured with acceleromyography .  Adverse respiratory events during transport to the PACU and during the first 30 min of PACU admission were also recorded . Results : A lower frequency of residual neuromuscular blockade in the PACU ( TOF ratio ≤ 0.9 ) was observed in the acceleromyography group ( 4.5 % ) compared with the conventional TOF group ( 30.0 % ; P < 0.0001 ) . During transport to the PACU , fewer acceleromyography patients developed arterial oxygen saturation values , measured by pulse oximetry , of less than 90 % ( 0 % ) or airway obstruction ( 0 % ) compared with TOF patients ( 21.1 % and 11.1 % , respectively ; P < 0.002 ) . The incidence , severity , and duration of hypoxemic events during the first 30 min of PACU admission were less in the acceleromyography group ( all P < 0.0001 ) . Conclusions : Incomplete neuromuscular recovery can be minimized with acceleromyographic monitoring . The risk of adverse respiratory events during early recovery from anesthesia can be reduced by intraoperative acceleromyography use We have assessed , in 200 patients , the determinants of the reversal time of competitive neuromuscular block by anticholinesterase when alcuronium and atracurium neuromuscular block were antagonized by neostigmine 0.04 and 0.08 mg kg-1 and edrophonium 0.5 and 1.0 mg kg-1 . A biexponential relationship was found between the reversal time ( time from injection of anticholinesterase to a train-of-four ratio of 70 % ) and the degree of neuromuscular block at reversal ( all groups ; F ratio , P less than 0.05 ) . Reversal time was determined by two processes : direct antagonism by the anticholinesterase and spontaneous recovery of the neuromuscular blocking agent , with the latter becoming the major determinant at profound levels of neuromuscular block ( 0 - 10 % of control twitch height ) . Neostigmine , in the doses studied , appeared to have a higher " ceiling " of neuromuscular block which it completely antagonized , although edrophonium had a more rapid onset of action . The reversal time for alcuronium became progressively longer relative to atracurium as neuromuscular block increased because of the slower spontaneous recovery rate . Avoidance of profound neuromuscular block at the completion of surgery is required to ensure reliable antagonism of the block within 5 - 10 min by an anticholinesterase . Neostigmine 0.08 mg kg-1 was found to be the most effective agent in antagonizing profound neuromuscular block Background Mivacurium , a nondepolarizing muscle relaxant , is hydrolyzed by butyrylcholinesterase . The use of butyrylcholinesterase for antagonism of profound mivacurium-induced blockade has not been studied in humans . In part 1 of this two-part study , the authors examined the relationship between the posttetanic count ( PTC ) and recovery from profound mivacurium-induced blockade . In part 2 , an attempt was made to antagonize a quantified level of profound mivacurium-induced blockade using either butyrylcholinesterase , edrophonium , or neostigmine . Methods Eighty-seven ASA physical status 1 or 2 adult patients were given 0.15 mg * symbol * kg sup -1 mivacurium during fentanyl-thiopental-nitrous oxide-isoflurane anesthesia . They were r and omly assigned to eight groups . Neuromuscular function was monitored by recording the mechanomyographic response of the adductor pollicis to PTC and train-of-four ( TOF ) stimulation in all patients except those in group 1 where the TOF was the only pattern used . In part 1 , neuromuscular function was allowed to recover spontaneously in ten patients ( group 1 ; control-TOF ) until TOF ratio ( the amplitude of the fourth evoked response as a fraction of the first evoked response : T4/T1 ) had reached 0.75 . The temporal relationship between PTC and the first reaction to TOF stimulation was determined in another 21 patients , and neuromuscular function in 10 of these patients was allowed to recover spontaneously until TOF ratio had reached 0.75 ( group 2 ; control-PTC ) . In part 2 , the antagonism of mivacurium-induced profound ( PTC greater or equal to 1 ; groups 3 - 6 ) and 90 % block ( groups 7 - 8 ) of twitch height were investigated in another 56 patients . Groups 3 and 7 received neostigmine 0.06 mg * symbol * kg sup -1 whereas groups 4 and 8 received edrophonium 1 mg * symbol * kg sup -1 , respectively . Groups 5 and 6 received exogenous human butyrylcholinesterase equivalent to activity present in 25 or 70 ml * symbol * kg sup -1 of human plasma , respectively . Results Neither butyrylcholinesterase nor edrophonium shortened the times from first PTC response to TOF = 0.75 compared to group 2 . Neostigmine result ed in prolongation of recovery time . There was a linear relationship ( r = -0.80 ; P = 0.00001 ) between PTC and time of onset of TOF response . Conclusions There appears to be no clinical advantage in attempting to antagonize profound mivacurium-induced neuromuscular blockade We have compared the antagonism of neuromuscular block produced by pipecuronium with pancuronium in 80 anaesthetized surgical patients using mechanomyography and electromyography .  Pancuronium 0.1 mg kg-1 or pipecuronium 0.07 mg kg-1 was given after induction of anaesthesia and neuromuscular block was adjusted to 75 % twitch depression at the time of antagonism . The following regimens were used : edrophonium 0.5 and 1.0 mg kg-1 , neostigmine 0.04 mg kg-1 , pyridostigmine 0.3 mg kg-1 and edrophonium 0.25 mg kg-1 with pyridostigmine 0.15 mg kg-1 .  Antagonism was evaluated also by the head lift test . There was no difference between the reversibility of neuromuscular block produced by pancuronium or pipecuronium . Edrophonium produced a significantly faster antagonism than neostigmine or pyridostigmine but onset of action was not significantly faster than that of edrophonium with pyridostigmine . All regimens produced 100 % ( or near 100 % ) antagonism of twitch response within 15 min . However , TOF fade antagonism was more complete with pyridostigmine , neostigmine and edrophonium 1.0 mg kg-1 than with edrophonium 0.5 mg kg-1 . The head lift test indicated somewhat less antagonism with edrophonium 0.5 and 1.0 mg kg-1 . Using five monitoring methods , the rank order of reversal potency was : pyridostigmine approximately neostigmine > edrophonium 1.0 mg kg-1 > edrophonium+pyridostigmine > edrophonium 0.5 mg kg-1 Purpose Mivacurium is metabolized by plasma cholinesterase catalyzed ester hydrolysis . Acetylcholinesterase antagonists used in the reversal of muscle relaxation may also inhibit plasma cholinesterase and , therefore , delay the hydrolysis of mivacurium . The clinical interaction between acetylcholinesterase antagonists and mivacurium induced neuromuscular blockade was studied . Method Intraoperative muscle relaxation was maintained with a mivacurium infusion to achieve a constant intense block ( first twitch , T1 , 2–3 % of control ) . Patients were r and omly divided into three groups . Patients in Group 1 received no anticholinesterase , in Group 2 neostigmine 0.07 mg · kg−1 , and in Group 3 edrophonium 1 mg · kg−1 . The times between termination of the mivacurium infusion ( Group 1 ) or the administration of the anticholinesterase ( Groups 2 and 3 ) to 25 % , 50 % , 75 % and 95 % T1 recovery , and to 50 % , 70 % and 90 % recovery in the ratio , T4/T1 ( TR ) were recorded . Result In the neostigmine Group , T1 recovery to 25 % , 50 % and 75 % ( 2.32 ± 1.41 , 3.90 ± 1.85 and 6.88 ± 2.6 
    Output:
    
The effect of neostigmine was not clarified at deeper mivacurium-induced NMB .
At deeper NMB only edrophonium accelerated the recovery