Final answer:
The neuromuscular blocking agents atracturium and cisatracurium are considered safe for use in patients with renal and liver dysfunction due to their inactivation by Hofmann elimination, which is independent of organ function. d-Tubocurarine and BONT, though effective, are not the preferred choices in such patients.
Step-by-step explanation:
In patients with renal and liver dysfunction, it is critical to use a neuromuscular blocking agent (NMBA) that has minimal to no reliance on these organs for metabolism and excretion. Among NMBAs, atracturium and cisatracurium are considered safe options because they undergo Hofmann elimination, a process that does not depend on organ function. These agents are degraded at physiological pH and temperature, resulting in inactivation and clearance independently of the liver and kidneys.
d-Tubocurarine and botulinum toxin (BONT), while effective neuromuscular blocking agents, are not ideal for patients with significant renal or liver impairment. d-Tubocurarine competitively blocks acetylcholine, causing muscle relaxation and paralysis, but its excretion may be compromised in renal dysfunction. BONT prevents acetylcholine release, leading to muscle relaxation and paralysis, but its safety profile in liver and renal dysfunction is not well established.