Adult: Infuse at an initial rate of 8-10 mcg/kg/min, adjusted every 3 minutes if needed by increments of 1 mcg/kg/min to a usual rate of 6-7 mcg/kg/min. Dosage is individualised according to response. Child: 2 months to 12 years Usual rate: 11-14 mcg/kg/min via IV infusion. >12 years Same as adult dose. Elderly: Dose reduction may be necessary.
Intravenous Endotracheal intubation
Adult: Initially, 150 mcg/kg, then 100 mcg/kg given 30 seconds after. Maintenance: 100 mcg/kg at approx 15-minute intervals. Dosage is individualised according to response. Child: 2-6 months Initially, 150 mcg/kg over 5-15 seconds; 7 months to 12 years Initially, 200 mcg/kg. Maintenance: 2 months to 12 years 100 mcg/kg given every 6-9 minutes. >12 years Same as adult dose. Dosage is individualised according to response. Elderly: Dose reduction may be necessary.
Intravenous Adjunct to general anaesthesia
Adult: Initially, 70-250 mcg/kg. Doses of up to 150 mcg/kg may be given over 5-15 seconds; higher doses must be administered over 30 seconds. Maintenance: 100 mcg/kg at approx 15-minute intervals. Dosage is individualised according to response. Child: 2-6 months Initially, 150 mcg/kg over 5-15 seconds; 7 months to 12 years Initially, 200 mcg/kg. Maintenance: 2 months to 12 years 100 mcg/kg given every 6-9 minutes. >12 years Same as adult dose. Dosage is individualised according to response. Elderly: Dose reduction may be necessary.
Special Patient Group
Patient with clinically significant CV disease, asthma or those unusually sensitive to falls in arterial blood pressure (e.g. hypovolaemic): Initial doses must be administered over 60 seconds.
Burn injury patients (≥20% of total BSA): Dose adjustment may be necessary. Administer a test dose of 15-20 mcg/kg, followed by appropriate dosing guided by monitoring of block with a nerve stimulator.
Obese patients (weighing ≥30% of their ideal body weight): Dose must be based on the ideal body weight.
Pharmacogenomics:
Mivacurium chloride is metabolised by plasma cholinesterase. Patients with genetic variation of plasma cholinesterase may have reduced plasma cholinesterase activity.
Individuals who are known or suspected of being homozygous for the atypical plasma cholinesterase gene (BCHE) are extremely sensitive to the neuromuscular blocking effect of mivacurium chloride. FDA drug label recommends great caution during the administration of mivacurium chloride due to risk of prolonged neuromuscular block.
Renal Impairment
Dose adjustment may be necessary.
Hepatic Impairment
Dose adjustment may be necessary.
Reconstitution
Infusion: May dilute in 5% dextrose for inj, 0.9% NaCl solution or Lactated Ringer's solution to a max concentration of 500 mcg/mL. Doses may also be given undiluted. Dilute immediately before use then administer thereafter.
Incompatibility
Incompatible with highly alkaline solutions having a pH of >8.5 (e.g. barbiturates).
Contraindications
Patients known or suspected to be homozygous for the atypical plasma cholinesterase gene.
Special Precautions
Patient with previous anaphylactic reaction to other neuromuscular blockers; clinically significant CV disease; conditions that may antagonise neuromuscular blockade (e.g. hypercalcaemia, respiratory alkalosis, peripheral neuropathies, demyelinating lesions, denervation, muscle trauma); conditions that may diminish plasma cholinesterase activity (e.g. anaemia, myxoedema, collagen diseases, peptic ulcer); conditions that may potentiate neuromuscular blockade (e.g. myasthenia gravis, neuromuscular disease, metabolic or respiratory acidosis, electrolyte abnormalities, Eaton-Lambert syndrome); asthma, hypovolaemia. Burn injury, obese or immobilised patients. Renal and hepatic impairment. Children and elderly. Pregnancy and lactation.
Adverse Reactions
Significant: Bradycardia, neuromuscular cross-sensitivity. Cardiac disorders: Transient tachycardia. General disorders and administration site conditions: Inj site reactions. Musculoskeletal and connective tissue disorders: Muscle spasms. Nervous system disorders: Dizziness. Respiratory, thoracic and mediastinal disorders: Bronchospasm, wheezing. Skin and subcutaneous tissue disorders: Erythema, urticaria, rash. Vascular disorders: Flushing, hypotension. Potentially Fatal: Severe anaphylactic reactions.
Monitoring Parameters
Monitor vital signs (e.g. blood pressure, heart and respiratory rate); degree of muscle paralysis (e.g. ventilator asynchrony, shivering, presence of spontaneous movement).
Overdosage
Symptoms: Prolonged muscle paralysis, and hypotension. Treatment: Maintain a patent airway and assisted positive ventilation until spontaneous respiration is adequate. Provide full sedation since consciousness is not impaired. Once evidence of spontaneous respiration is present, administer anticholinesterase agents (e.g. neostigmine) with an anticholinergic agent (e.g. atropine, glycopyrrolate) to hasten recovery. Provide CV support by proper positioning and administration of fluids or vasopressors as needed.
Drug Interactions
Increased neuromuscular blocking effects with inhalational anaesthetics (e.g. enflurane, isoflurane, sevoflurane, halothane), antibiotics (e.g. aminoglycosides, polymyxin, tetracyclines, clindamycin), antiarrhythmics (e.g. quinidine, lidocaine, Ca channel blockers), diuretics (e.g. furosemide, acetazolamide), ganglion blocking agents (e.g. hexamethonium, trimetaphan), Mg salts, ketamine, and lithium salts. Prolonged neuromuscular blocking effects with antimitotic drugs, MAOIs, organophosphates, anticholinesterases, bambuterol, SSRIs. May result in a prolonged and complex block with depolarising relaxant (e.g. suxamethonium chloride).
Action
Description: Mivacurium chloride is a short-acting non-depolarising neuromuscular blocker which inhibits skeletal muscle contractile activity by antagonising acetylcholine. It competitively binds to cholinergic receptors on motor endplates in skeletal muscles leading to muscle paralysis. Onset: Neuromuscular blockade (dose-dependent): 1.5-3 minutes (adults); 1.5 minutes slower (elderly); child (faster than adults). Duration: 15-20 minutes (dose-dependent). Pharmacokinetics: Absorption: Time to peak plasma concentration: 2.3-4.9 minutes. Distribution: Volume of distribution: 147-274 mL/kg. Metabolism: Undergoes enzymatic hydrolysis by plasma cholinesterase to form inactive metabolites. Excretion: Via urine (approx 7% as unchanged drug); bile. Elimination half-life: Approx 2 minutes.
Chemical Structure
Mivacurium chloride Source: National Center for Biotechnology Information. PubChem Compound Summary for CID 5281080, Mivacurium chloride. https://pubchem.ncbi.nlm.nih.gov/compound/Mivacurium-chloride. Accessed Apr. 27, 2022.
Storage
Store below 25°C. Do not freeze. Protect from light. Storage requirement may vary between individual products (refer to detailed product guideline).
M03AC10 - mivacurium chloride ; Belongs to the class of other quaternary ammonium-containing agents used as peripherally-acting muscle relaxants.
References
Annotation of FDA Label for Mivacurium Chloride and BCHE. Pharmacogenomics Knowledgebase (PharmGKB). https://www.pharmgkb.org. Accessed 26/04/2022.Anon. Mivacurium. Lexicomp Online. Hudson, Ohio. Wolters Kluwer Clinical Drug Information, Inc. https://online.lexi.com. Accessed 05/05/2021.Buckingham R (ed). Mivacurium Chloride. Martindale: The Complete Drug Reference [online]. London. Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 05/05/2021.Joint Formulary Committee. Mivacurium. British National Formulary [online]. London. BMJ Group and Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 05/05/2021.Mivacron Injection (Aspen Medical Products Malaysia Sdn Bhd). National Pharmaceutical Regulatory Agency - Ministry of Health Malaysia. https://www.npra.gov.my. Accessed 05/05/2021.Mivacron Injection 2 mg/mL (Aspen Pharma Trading Limited). MHRA. https://products.mhra.gov.uk. Accessed 05/05/2021.Mivacron Injection, Solution (Abbott Laboratories). U.S. FDA. https://www.fda.gov. Accessed 05/05/2021.
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