A 68-year-old patient with CKD stage 4 (eGFR 18) is scheduled for hip replacement. Which neuromuscular blocking agent choice and reversal strategy is MOST appropriate to minimise risk from altered pharmacokinetics?

• A Pancuronium reversed with neostigmine/glycopyrrolate
• B Cisatracurium with no reversal needed
• C Atracurium reversed with neostigmine — Hofmann elimination makes it safe regardless of renal function
• D Rocuronium reversed with sugammadex ✓

Explanation

Cisatracurium and atracurium undergo Hofmann elimination (spontaneous non-enzymatic degradation) making their primary clearance renal-independent, which is an advantage in renal failure. However, atracurium's metabolite laudanosine accumulates in renal failure and can cause CNS excitation/seizures, whereas cisatracurium produces less laudanosine. Rocuronium is predominantly hepatically excreted, but with sugammadex reversal its residual block can be reliably and completely reversed regardless of renal function; sugammadex-rocuronium complex is excreted renally but this is clinically safe. Pancuronium is significantly renally excreted and prone to prolonged block in CKD — contraindicated. While cisatracurium is also a valid choice, rocuronium with sugammadex provides reliable RSI capability plus complete reversal, which is the current preferred approach.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.