Should be administered in carefully adjusted dosage by or under the supervision of experienced clinicians. It is recommended to employ a peripheral nerve stimulator to monitor drug response (particularly in ICU), the need for additional relaxants, and adequacy of spontaneous recovery or antagonism. Doxacurium chloride injection is acidic (pH 3.9 to 5.0) and may not be compatible with alkaline solutions having a pH greater than 8.5 (e.g. barbiturate solutions). Contains benzyl alcohol (exposure to excessive amounts of benzyl alcohol has been associated with toxicity (hypotension, metabolic acidosis), particularly in neonates (special caution in high dosages of medications containing this preservative). Does not counteract bradycardia produced by anesthetics/vagal stimulation. Severe anaphylactic reactions have been reported (due to the potential severity of these reactions, all necessary precautions, such as the immediate availability of appropriate emergency treatment, should be taken). Precautions should also be taken in those individuals who have had previous anaphylactic reactions to other neuromuscular-blocking agents since cross-reactivity between neuromuscular-blocking agents, both depolarizing and non-depolarizing, has been reported in this class of drugs. Antagonists (such as neostigmine) should not be administered prior to the demonstration of some spontaneous recovery from neuromuscular block. Antagonism may be delayed in the presence of debilitation, carcinomatosis, and the concomitant use of certain broad-spectrum antibiotics or anesthetic agents and other drugs which enhance neuromuscular block or separately cause respiratory depression. The use of edrophonium is not recommended for reversal from moderate to deep levels of block (the use of pyridostigmine has not been studied). Alkalosis, hypercalcemia, demyelinating lesions, peripheral neuropathies, denervation, infection, muscle trauma, and diabetes mellitus may result in antagonism of neuromuscular blockade. Electrolyte abnormalities, severe hyponatremia, severe hypocalcemia, severe hypokalemia, hypermagnesemia, neuromuscular diseases, acidosis, acute intermittent porphyria, Eaton-Lambert syndrome, myasthenia gravis, renal failure, and hepatic failure may result in potentiation of neuromuscular blockade. The 2004 Surviving Sepsis Campaign guidelines recommend avoiding use of neuromuscular blockers if at all possible in the septic patient due to risk of prolonged neuromuscular blockade following discontinuation. The 2002 ACCM/SCCM/ASHP clinical practice guidelines recommend optimizing sedatives and analgesics prior to initiation, and monitoring and adjusting accordingly during course (neuromuscular blockers do not relieve pain or produce sedation).