mivacurium

[Idiopathic]

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anyone use it? im not sure we have it here...is it even still around in the US? seems like a great drug for rapid onset, infusion characteristics, etc. is it the histamine that made it fall out of favor? wikipedia says its still very commonly used in the UK.

 

[Gern Blansten]

I believe that it is no longer manufactured/available in the U.S.
The histamine was one issue. Some thought the level of paralysis was sub optimal. One of my attendings referred to it as "Move-acron" instead of mivacron.
Another would combine it with rocuronium for RSIs(1/2 miv and 1/2 roc). There was a paper years ago that claimed the combo was perfect for RSIs where succinylcholine was contraindicated and you wanted fairly rapid reversibility. Claimed good intubating conditions within 60 sec and reversibilty after 10-15 min. In my few experiences, I felt the claim was correct. Admittedly, I only tried the combo a couple times with that one attending.

 

[jwk]

is it the histamine that made it fall out of favor?

Nah - it didn't work.

 

[dhb]

The histamine isn't a major concern. You can get the same effect with 0.3mg/kg of roc.

 

[kmurp]

I miss it for short cases like tonsils.

 

[tucker27705]

I think others may have commented on this before, but it seems like a good time to bring it up again, intubating without relaxant.

This idea wasn't even mentioned during (my) residency. First day in the peds room here in PP, one of the old guys came in to see how I was doing, and politely suggested getting the kid deep with prop, then using no relaxant. Now I do all my tonsils etc that way. I even have done it with some adults. Heck, when I don't use succ and go with vec (90% of the time) I don't even really wait long enough for it to really kick in.

In other words, if you time sliding that tube in and don't bang around, you really don't need relaxant. But I can see why we never did that as a resident. I find the biggest advantage of relaxant is allowing one to ventilate a hefty patient. Once the chest relaxes, ventilation is usually fairly easy with anyone, unless there is also lots of facial hair and/or no teeth.

What do others think?

Tuck

 

[Jay K]

This idea wasn't even mentioned during (my) residency. First day in the peds room here in PP, one of the old guys came in to see how I was doing, and politely suggested getting the kid deep with prop, then using no relaxant. Now I do all my tonsils etc that way.

ENT clinics PP peds T&A's all intubated sans muscle relaxant.

Sevo mask down, IV, fent, prop, tube, dex, ondansetron, spont vent by the time turn 90 degrees, IM meperidine, rectal tylenol by RN, 70% N2O wakeup - cake

You won't survive PP peds T&A room wakeup & turnover otherwise.

 

[Idiopathic]

I think others may have commented on this before, but it seems like a good time to bring it up again, intubating without relaxant.

This idea wasn't even mentioned during (my) residency. First day in the peds room here in PP, one of the old guys came in to see how I was doing, and politely suggested getting the kid deep with prop, then using no relaxant. Now I do all my tonsils etc that way. I even have done it with some adults. Heck, when I don't use succ and go with vec (90% of the time) I don't even really wait long enough for it to really kick in.

In other words, if you time sliding that tube in and don't bang around, you really don't need relaxant. But I can see why we never did that as a resident. I find the biggest advantage of relaxant is allowing one to ventilate a hefty patient. Once the chest relaxes, ventilation is usually fairly easy with anyone, unless there is also lots of facial hair and/or no teeth.

What do others think?

Tuck

peds vs. adult = totally different scenarios. occasionally on the floor i did some intubations with remifentanyl (love it) as opposed to sux/roc or without paralytic, but i reserved that for special cases...it was very rare that i put someone to sleep with the intention of intubating without paralytic.

the best view is the first view and the first view of a non-relaxed patient may be f-ing awful. so now what. do you go down the algorithm or do you do what you should have done the first time. so, i treat adults differently.

kids, if you get them deep enough, you can intubate them all. i wouldnt have paralyzed anyone under 5 had my attendings not made me.

 

[Idiopathic]

ENT clinics PP peds T&A's all intubated sans muscle relaxant.

Sevo mask down, IV, fent, prop, tube, dex, ondansetron, spont vent by the time turn 90 degrees, IM meperidine, rectal tylenol by RN, 70% N2O wakeup - cake

You won't survive PP peds T&A room wakeup & turnover otherwise.

exactly, how else are you going to do 10 T+A before 3PM

 

[cchoukal]

I believe that it is no longer manufactured/available in the U.S.
The histamine was one issue. Some thought the level of paralysis was sub optimal. One of my attendings referred to it as "Move-acron" instead of mivacron.

That's funny; attendings where I trained used to call it "Maybe-curium." All the more interesting because one of our faculty developed it.

 

[proman]

That's funny; attendings where I trained used to call it "Maybe-curium." All the more interesting because one of our faculty developed it.

Did that guy call it Moneyinthebancurium?

 

[urge]

ENT clinics PP peds T&A's all intubated sans muscle relaxant.

Sevo mask down, IV, fent, prop, tube, dex, ondansetron, spont vent by the time turn 90 degrees, IM meperidine, rectal tylenol by RN, 70% N2O wakeup - cake

You won't survive PP peds T&A room wakeup & turnover otherwise.

That's the cadillac of tonsil anesthesia.

fent, prop, dex, zofran, demerol, and tylenol!

How much IM demerol are you giving? Why not IV?

 

[Arch Guillotti]

In an urgent or emergent situation (floor/ICU intubations) giving relalaxant has been debated here before with no clear consensus. Though I didn't give sux too often on the floor, I agree that relaxing gives the best conditions.

An elective case is different, I think that you can get great intubating conditions most of the time without relaxant if you plan it carefully.

 

[Bertelman]

Heck, when I don't use succ and go with vec (90% of the time) I don't even really wait long enough for it to really kick in.

In other words, if you time sliding that tube in and don't bang around, you really don't need relaxant. But I can see why we never did that as a resident.

Why wouldn't you tech that in residency? I frequently see cords move when I get my view. Line it up, sneak it in before the cords know what hit them. I can't remember the last time I waited 3 min for vec. I give 1-2 cc before propofol, give the rest, then usually tube in 60-90 sec, depending on the pt.

 

[cchoukal]

Did that guy call it Moneyinthebancurium?

No, but he also helped develop methylnaltrexone, and he was not afraid to wear the manufacturer's logo hat around the department and boast about their stock price.

 

[Licoricestick]

I've used it, we still have it here, they all go red from the histamine release, and it doesn't really seem to work (let alone in a predictable fashion). Only reason most of my bosses ever use it is as a teaching tool (to make sure we're familiar with everything available).

 

[dhb]

I use it too and it's not as bad as most here say it is. If you don't give a priming dose you just have to wait a long time.

 

[Jay K]

That's the cadillac of tonsil anesthesia.

fent, prop, dex, zofran, demerol, and tylenol!

How much IM demerol are you giving? Why not IV?

Interestingly enough, it's our surgeons who like the "Cadillac" and since it's their overhead I have no qualms giving what I can to ensure happy patients and parents. It also makes sense cause you can't stack up the surgery center PACU with puking and crying kids if you've got 2-3 rooms of stacked ENT coming out every 15-30 min. IM meperidine theoretically for slow release along with the rectal Tylenol for post-op pain on the car ride home. I dose 0.5mg/kg, but some of my partners dose more.