Question

A patient with a bilirubin value of 8 mg/dl and a serum creatinine of 1.9 mg/dl is planned for surgery. What is the muscle relaxant of choice in this patient?

• A. Vecuronium
• B. Pancuronium
• C. Atracurium
• D. Rocuronium

Hint:

Which relaxant clears by Hofmann elimination, independent of liver and kidney?

Answer 1

The Correct Option is C

The question is really asking which non-depolarising blocker you can give safely when both the liver and the kidney are not working well. The clues are a high bilirubin (8 mg/dl) and a high creatinine (1.9 mg/dl).

Think about how each drug leaves the body. Pancuronium and vecuronium both lean on renal excretion, and vecuronium also uses biliary excretion, so a damaged kidney or liver makes their effect last far too long. Rocuronium is mostly handled by the liver, so a jaundiced patient will stay paralysed longer than expected.

Atracurium breaks down on its own through Hofmann elimination, a spontaneous chemical degradation at normal body pH and temperature, plus ester hydrolysis in plasma. Neither pathway needs a functioning liver or kidney. That makes its duration predictable even when both organs fail, which is exactly this patient's situation.

So the safe pick is atracurium.

\[\boxed{\text{Atracurium}}\]