Mivacurium

Mivacurium

Clinical data
Drug class	Neuromuscular blocker
Routes of administration	Intravenous
Pharmacodynamics
Mechanism of action	Nicotinic acetylcholine antagonism
Pharmacokinetics
Physical and chemical data
Article quality
Editor rating	Unrated
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Mivacurium is a short acting non-depolarizing neuromuscular blocking agent used for optimizing tracheal intubation conditions, surgical relaxation, optimizing mechanical ventilation, and preventing fasciculation from succinylcholine when administered prior. This is medication is available in most of the world, however, it is not sold in the United States of America.

Uses

• Optimizing tracheal intubation condition among patients with renal or hepatic dysfunction
  • Abduction of vocal cords
  • Opening of mouth
  • Reduction in coughing and gagging
• Provide surgical relaxation among patients with renal or hepatic dysfunction
• Optimizing mechanical ventilation conditions among patients with renal or hepatic dysfunction
  • Reduction in bucking/coughing
  • Reduction in breath stacking

Contraindications

Absolute contraindications

Known hypersensitivity

Precautions

• Prolonged duration of action in patients who are homozygous for atypical pseudocholinesterase
• Large doses of mivacurium can be divided into smaller doses to avoid hemodynamic side effects from the histamine release
  • Myasthenia gravis/myathenic syndrome
  • Amyotrophic lateral sclerosis
  • Autoimmune disorders including polymyositis, dermatomyositis and systemic lupus erythematous
  • Familial periodic paralysis hyperkalemia
  • Guillain-Barré syndrome
  • Muscular dystrophy (Duchenne type)
  • Myotonia including dystrophic, congenital,, and paramyotonia
  • Patient may have resistance include:
    • Burn injury
    • Cerebral palsy
    • Hemiplegia (on the affected side)
    • Muscular denervation
    • Severe chronic infection such as tetanus and botulism

Pharmacology

Pharmacodynamics

Eliminated via pseudocholinesterase

Mechanism of action

Competitive antagonism of acetylcholine at the post junctional receptors preventing depolarization of the muscle preventing any movement. Only one molecule of the neuromuscular blocker is needed to prevent activation of the receptor as it competes with acetylcholine at the two binding sites.

Adverse effects

• Anaphylactic reaction due to the ammonium ion in the NMB
• Histamine release
• Muscle weakness or myopathy due to persistent failure of neuromuscular transmission and immobilization-induced atrophy of diaphragm when used for a prolonged duration
• Posttraummatic stress syndrome from awareness during paralysis if sedation is not used adequately.
• Impairment of ventilation-perfusion distribution and decreased right ventricular end-diastolic volume due to abolishment of spontaneous breathing.

Pharmacokinetics

Duration of action

Chemistry and formulation

Comprised of a mixture of 3 stereoisomers, one of which -the cis-cis isomer- is less than one-tenth as potent as the trans-trans and cis-trans isomers.

References

• Frampton JE, McTavish D. Mivacurium. A review of its pharmacology and therapeutic potential in general anaesthesia. Drugs. 1993 Jun;45(6):1066-1089. doi: 10.2165/00003495-199345060-00009. PMID: 7691494.
• Goodwin, G., Joseph, V. (2015). Neuromuscular Blockers. In: Kaye, A., Kaye, A., Urman, R. (eds) Essentials of Pharmacology for Anesthesia, Pain Medicine, and Critical Care. Springer, New York, NY. https://doi-org.laneproxy.stanford.edu/10.1007/978-1-4614-8948-1_12