Choice of muscle relaxants in patients with heart disease

The presence or absence of circulatory effects induced by muscle relaxants is often cited in the decision process for selection for the most appropriate drug for production of skeletal muscle paralysis in patients with heart disease undergoing surgery. With the exception of pancuronium, all the other currently available nondepolarizing muscle relaxants are devoid of circulatory effects or evoke histamine release only when large doses (about 3×ED95) are administered rapidly. Indeed, it seems undeniable that the circulatory effects of muscle relaxants, when they do occur, are modest, transient, and rarely of clinical significance. More important than muscle-relaxant-induced circulatory effects is their recovery profile and the likelihood that residual (“subclinical”) skeletal muscle paralysis will persist despite drugassisted antagonism. In this regard, when the issue of patient safety is considered, the higher cost of short-acting and intermediate-acting nondepolarizing muscle relaxants seems justifiable. What a difference 10 years can make!29