Increasing the available ACh at the NMJ (a nicotinic receptor) also stimulates muscarinic cholinergic receptors. Of particular concern is the effect on cardiac conduction. Unopposed muscarinic effects impair sinus-node conduction, resulting in sinus bradycardia, junctional rhythms, and in the extreme asystole. To prevent this, anticholinergics are administered in concert with the acetylcholinesterase. Glycopyrrolate, 7 to 15 mcg/kg, is coadministered with neostigmine and atropine, 7 to 10 mcg/kg, with edrophonium so the onset of anticholinergic activity is appropriately timed with the onset of acetylcholinesterase inhibition.
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