rocuronium + atracurium + mivacurium

This is a combination of three non-depolarizing neuromuscular blocking agents (NMBAs) used in anesthesia. Each component has distinct properties: **Rocuronium**: An intermediate-acting aminosteroid NMBA with rapid onset (60-90 seconds). It is less potent than vecuronium but can be used as an alternative to succinylcholine for rapid sequence intubation in larger doses. It is primarily eliminated via the bile. **Atracurium**: An intermediate-acting NMBA with onset of approximately 90 seconds and duration of 30 minutes or less. It can cause histamine release leading to transient hypotension. **Mivacurium**: A short-acting NMBA with onset of approximately 90 seconds and duration of 12-18 minutes. It is rapidly hydrolyzed by plasma cholinesterase and can cause histamine release leading to hypotension. When these agents are combined, they can produce synergistic effects. Studies have shown that combining different chemical classes of non-depolarizing NMBAs (such as rocuronium with cisatracurium or mivacurium with atracurium) produces synergistic responses rather than simply additive effects.