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LETTERS TO THE EDITOR

Mivacurium Administration in Children with Duchenne Muscular Dystrophy

The University of Missouri Department of Child Health Columbia, MO 65212

I read with interest the report of Uslu et al. (1) concerning mivacurium in a child with Duchenne muscular dystrophy (DMD). The authors state that there is no information concerning the use of mivacurium in DMD. In 1994, we published an article about a series of seven patients (8.3 to 14.4 yr old) in whom mivacurium was used to provide neuromuscular blockade during orthopedic procedures (2). After a bolus of mivacurium (0.2 mg/kg), the time to recovery of the first twitch varied from 12 to 18 min. Continuous infusion requirements varied from 3 to 20 µg · kg^-1 · min^-1. Although Uslu et al. suggested that patients with DMD have responses to mivacurium that are close to normal, our larger series demonstrates interpatient variability with increased sensitivity in some patients with a longer duration of neuromuscular blockade after a bolus dose and decreased infusion requirements when compared with children with normal neuromuscular function (3, 4). In our series, the patients’ sensitivity to neuromuscular blockade did not correlate with their preoperative status. We noted normal sensitivity in patients that were wheelchair users and increased sensitivity in those that were ambulatory. We agree that mivacurium may be preferred in DMD as prolonged durations of action have been noted with vecuronium and atracurium in this population.

References

1. Uslu M, Mellinghoff H, Diefenbach C. Mivacurium for muscle relaxation in a child with Duchenne’s muscular dystrophy. Anesth Analg 1999;89:340–1.[Free Full Text]
2. Tobias JD, Atwood R. Mivacurium in children with Duchenne muscular dystrophy. Anaesth 1994;4:57–60.
3. Alifimoff JK, Goudsouzian NG. Continuous infusion of mivacurium in children. Br J Anaesth 1989;63:520–4.[Abstract/Free Full Text]
4. Brandom BW, Sarner JB, Woelfel SK. Mivacurium infusion requirements in pediatric surgical patients during nitrous oxide-halothane and during nitrous oxide-narcotic anesthesia. Anesth Analg 1990;71:16–22.[Abstract/Free Full Text]

Response

Department of Anesthesiology University of Cologne 50924 Cologne, Germany

We congratulate Drs. Tobias and Atwood (1) for having collected as many as seven cases of Duchenne muscular dystrophy with mivacurium used for muscle relaxation. We deeply regret that this interesting study escaped our literature research. However, in retrospect, we still were unable to trace this paper in a data base like silver platter although Paediatric Anaesthesia is one of its source journals.

Tobias’ and Atwood’s article (1) represents a retrospective study based on the evaluation of patient records. We understand that there was no underlying uniform protocol for mivacurium administration and that neuromuscular transmission was monitored by visual or tactile evaluation of the train-of-four response. Residual neuromuscular was antagonized by neostigmine in all patients.

In contrast, our case report was subject to a prospective design characterized by (i) mivacurium administration according to a predetermined protocol, (ii) monitoring of neuromuscular transmission by simultaneous recording of both the evoked twitch tension and the evoked compound EMG until almost complete recovery of neuromuscular transmission, and (iii) no cholinesterase inhibitors used.

Because of this design, our report (2) retains originality, even in the light of Tobias’ and Atwood’s contribution (1). The latter, of course, deserves the credit of the very first publication on mivacurium in Duchenne muscular dystrophy (1). As far as comparable by study design, our data are in line with those of Tobias and Atwood (1).

References

1. Tobias JD, Atwood T. Mivacurium in children with Duchenne muscular dystrophy. Anaesth 1994;4:57–60.
2. Uslu M, Mellinghoff H, Diefenbach C. Mivacurium for muscle relaxation in a child with Duchenne’s muscular dystrophy. Anesth Analg 1999;89:340–1.

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