RSPT 1213 Basic Respiratory Care Pharmacology: Unit 5: sedatives, Paralytics and Surface ActiveCase Studies KEY

Name:Date: 2008

Case study #1

Your patient is a 45 YO LAF who is going to surgery in the morning for a total hysterectomy. Because there is a concern about cancer, the operation will be via the abdomen rather than a vaginal approach.

  1. Identify the types of drugs that this patient might get the day before the surgery.
  • Analgesics for pain relief without loss of consciousness
  1. Identify the side effects of these drugs.
  • Analgesics: both acetaminophen & NSAID have liver damage as a side effect
  • Narcotic analgesic: decrease ventilatory drive and lower blood pressure most of these drugs are addictive
  1. Identify the type of drugs that this patient might get the night before surgery.
  2. Narcotic analgesic, hypnotics & larger doses of anti-anti-anxiety for sleep the night before surgery
  3. Identify the side effects of these drugs.
  4. hypnotics : loss of consciousness, decreased blood pressure and depressed ventilatory drive. Loss of REM sleep can effect mental status
  5. larger doses of anti-anxiety loss of consciousness, decreased blood pressure and depressed ventilatory drive.
  6. Once the patient goes into the OR, what types of drugs will she get for pain?
  7. Anesthetics by IV such as those in the barbiturate family are used to induce anesthesia.
  8. These are frequently used with the inhaled anesthetics for general anesthesia.
  9. What would be the advantage of giving more than one drugs for the same indication?
  • Because all CNS depressants have synergistic or potentiating interactions with one another, mixing them will increase the level of sedation needed for general anesthesia

Case study # 2

Your patient is an 18 YO WM who was in an MVA [motor-vehicle accident]. Because he has compound fractures of his pelvic and legs, we need to operate.

  1. Differentiate between general anesthesia and local anesthesia.
  2. We use a combination of different CNS depressants, both inhaled and IV to induce general anesthesia in which the patient has complete loss of sensation, loss of consciousness and loss of reflexes.
  3. A local anesthetic is used to block pain receptors in a single part of the body so that the patient never losses consciousness. Sometimes we need to give anti-anxiety to calm the patient during these procedures, but the patient should never lose consciousness
  4. Once he is intubated, what type of drugs will he get to minimize trauma to the muscles that will be cut.
  5. Paralytic drugs will relax the muscles so trauma is minimized
  6. List the side effects of paralytic agents.
  7. The patient has no loss of consciousness, no loss of sensation but he will have total loss of motor neuron.
  8. He cannot move. He cannot protect his airway, he cannot breathe. His blood pressure can drop due to loss of muscle action on lower extremities’ blood vessels
  9. Differentiate between reversible and non-reversible paralytic agents.
  • non-reversible paralytic agents are short acting and used to induce paralysis for less than 20-30 minutes for short procedures such as intubation. These drugs work by causing depolarization of the muscle so that teteny results
  • reversible paralytic agents are used for longer procedures such as while the patient is in surgery or while the patient is on mechanical ventilation. These drugs work by competing with acetylcholine at the skeletal muscle’s nerve endings.
  1. Give an example of a paralytic agent that isreversible?
  • tubocurarine & pancuronium [Pavulon]
  1. Discuss the specific side effects of general anesthesia.
  • During general anesthesia the patient’s airway and breathing must be maintained and the patient’s Sp02, exhaled C02 and BP monitored constantly because the patient has loss reflexes that protect the airway and his CNS the ability to notice hypercapnia & hypoxia as well as acidosis. There can be low blood pressure from both these drugs and immobility
  1. Which of these paralytic agents would be used for a surgical procedure that might last as long as an hour?
  • We would use a reversible paralytic agent such as tubocurarine & pancuronium [Pavulon]
  1. Once this patient is out of surgery and in the Recovery Room, what drug might he get to reverse the narcotic?
  2. Narcotics are reversed by narcan TM or naloxone
  3. What drug might he get to reverse the paralytic agent
  4. These drugs can be reversed by neostigmine.

Case study # 3

Your patient is a 35 YO BM with is history of seizures associated with a carbon monoxide exposure 3 years ago that resulted in hypoxic encephopathy. He was trached with a # 6 shiley at that time, because he could protect his airway. He frequently has serious pain from muscle cramps around the hips and legs.

  1. Identify the type of drugs he would get for the seizures.
  2. Anti-epilepsy drugs or anti-seizure
  3. Discuss the side effect of these drugs
  4. at lower dose reduce excessive EEG activity without depressing the CNS, but at high doses can start affecting consciousness
  5. Identify the type of drugs he would get for the muscle cramps
  • Anti-spasmodics / muscle relaxers are used for analgesics when the pain is related to muscle spasm
  1. Discuss the side effects of these drugs
  • drowsiness, dizziness and physical dependence
  1. How could getting these drugs adversely affect his ability to protect his airway?

Loss of reflexes, although in his case, because he is already trached, this would be minimal we would worry more that the drugs might decrease his ventilatory drive

Case study #4

Your patient is a 2 hour-old 28 week premature infant who presents in such respiratory distress that he is intubed with a 2.5 endotracheal tube. He has crackles and diminishedbreath sounds in the bases.The baby is 1800 grams.

  1. What drug would you recommend at this point?
  2. We need to instill exdogenous surfactant
  3. How would this help the baby?
  4. surfactant to decrease ST which increases the lung compliance and makes the WOB more normal
  5. What dose would you give this infant?
  6. Could give one of three surfactants: Exosurf TM, Survanta TM , Infasurf TM
  7. What are the side effects of this drug?
  • Immediately, instillation of the drug can become an airway obstruction so that the patient can have hypoxemia, possibly go apnic, become bradycardic and require bagging BUT -
  • Within a few minutes the compliance can improve so much that the same PIP and PEEP are now excessive and the Pa02 will rise rapidly so we might have to decrease the settings.
  1. Differentiate betweenProphylactic and rescue treatment
  • Prophylactic all infants below 1250-1350 grams get dose
  • rescue treatment only kids with s/s of respiratory distress should get these expensive drugs
  1. How often can you repeat this drug?

Exosurf TM, Q 12 hours

Infasurf TM and Survanta TM Q 6 hours

  1. Discuss the route of this drug.
  2. Instillation down the ET tube. Divide dose and give a little at a time so that the airway is not obstructed completely