IV Neostigmine for Colonic Pseudo-Obstruction in Adults

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The purpose of this guideline is to describe the process and restrictions for the safe administration of IV neostigmine in the management of colonic pseudo-obstruction.

  1. Indications
    1. Acute colonic pseudo-obstruction or colonic ileus with absence of mechanical obstruction and failure to improve with conservative management
    2. Patient must be located in a monitored bed (See monitoring section for details)
  2. Dosing and Administration
    1. Continuous infusion
      1. Neostigmine infusion 5 mg in 50 ml 0.9% NaCl
      2. Start at 0.4 mg/hour. If no response after 8 hours and CrCl ≥ 30 ml/min, may increase to 0.8 mg/hour. (Dose increase not recommended for CrCl < 30 ml/min due to accumulation in renal dysfunction.)
      3. Continue until patient passes stool
      4. Maximum recommended duration of infusion 24 hours for CrCl ≥ 30 ml/min, 12 hours for CrCl < 30 ml/min
  3. Contraindications
    1. Known or suspected intestinal ischemia
    2. Risk of intestinal ischemia due to high dose vasopressors
    3. Documented or suspected intestinal perforation
    4. Baseline HR < 60 bpm or SBP < 90 mmHg
    5. AV conduction disturbances
    6. Active bronchospasm
  4. Precautions
    1. Adverse effects
      1. Bradycardia
      2. Hypotension
      3. Abdominal pain
      4. Increased sputum and saliva production
    2. Order atropine 1 mg IV PRN symptomatic bradycardia
    3. If symptomatic hypotension and bradycardia not responsive to atropine, epinephrine and other emergency drugs are available in code carts on each unit
  5. Monitoring
    1. Continuous infusion
      1. ECG monitoring is required from the start of the infusion until 4 hours after infusion stopped.
      2. Vital signs (Blood pressure, heart rate, respiratory rate and SPO2)
        • Immediately before infusion initiation
        • q1 hour x 2 after initiation or with a dosage increase
        • Then q4 hours
        • Finally, 4 hours after the infusion is discontinued
      3. Patient is to be placed on bed rest with bedside commode privileges
      4. Contact MD when patient passes stool for reassessment of need to continue infusion


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  1. Title: IV Neostigmine for Colonic Pseudo-Obstruction in Adults
  2. Author:  Michigan Medicine
  3. Source: The URL where the image is hosted.
  4. License: “CC BY-NC 4.0”

IV Neostigmine for Colonic Pseudo-Obstruction in Adults,  Michigan Medicine, Dept of Surgery,  “CC BY-NC 4.0”


1. Ponec RJ, Saunders MD, Kimmey MB. Neostigmine for the treatment of acute colonic pseudo-obstruction. NEJM. 1999;341:137-141.
2. Van der Spoel JI, Oudemans-van Staaten HM, Stoutenbeck CP, Bosman RJ, Zandstra DF. Neostigmine resolves critical illness-related colonic ileus in intensive care patients with multiple organ failure – a prospective, double-blind, placebo-controlled trial. Intensive Care Med. 2001;27: 822-827.

Last reviewed: 09 June 2021