Cairo: Pilbeam's Mechanical Ventilation, 7th Edition

Chapter 15: Sedatives, Analgesics, and Paralytics

WorkBook Answer Key

KEY TERMS CROSSWORD PUZZLE

CHAPTER REVIEW QUESTIONS

1. Sedatives reduce anxiety and agitation and promote sleep and anterograde amnesia.
2. Paralysis is used to facilitate invasive procedures, such as intubation, to ensure the stability of
an airway and to decrease mean airway pressure during uncoordinated or uncontrolled
mechanical ventilation.
3. (a) Benzodiazepines (diazepam, midazolam, and lorazepam), (b) opioids (morphine, fentanyl),
neuroleptics (haloperidol), (c) anesthetic agents (propofol), and (d) opioids (morphine, fentanyl).
4. Minimal Sedation

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WorkBook Answer Key 15-2

Patients can respond to verbal commands, although cognitive function may be impaired.
Ventilatory and cardiovascular functions are unaffected.
Moderate Sedation (Conscious Sedation)
The patient can perform purposeful response following repeated or painful stimulation. (Note:
Reflex withdrawal from painful stimulus is not considered a purposeful response.) Spontaneous
ventilation is adequate, and cardiovascular function is usually maintained.
Deep Sedation
The patient is not easily aroused but can respond to painful stimulation. Spontaneous ventilation
and maintenance of patent airway may be inadequate. Cardiovascular function is usually
maintained.
Anesthesia
This level involves general anesthesia, spinal, or major regional anesthesia; local anesthesia is
not included. Patient cannot be aroused, even by painful stimulation. Ventilatory assistance is
typically required (i.e., artificial airway and positive-pressure ventilation). Cardiovascular
function may be impaired.
5. Deep sedation may be required during the initial phases of mechanical ventilation, especially
when the patient is asynchronous.
6. If sedation is necessary during weaning from mechanical ventilation, minimal levels of
sedation should be used.
7. Ramsay Sedation Scale (RSS), the Motor Activity Assessment Scale (MAAS), the Sedation-
Agitation Scale (SAS), and the Comfort Scale.
8. A score of 2-4 on the Ramsay scale indicates adequate sedation.
9. A score of 1 indicates the need for sedation.
10. Scores of 5-6 indicate oversedation for a patient.
11. Benzodiazepines are the drugs of choice for anxiety because of their ability to produce
anxiolytic, hypnotic, muscle relaxing, anticonvulsant, and anterograde amnesic effects.
12. Benzodiazepines depress the CNS by binding to receptors in the GABA receptor complex on
neurons in the brain. This increases the chloride permeability of the neuron, which in turn
hyperpolarizes the neuron, making it less likely to depolarize.
13. Factors that influence the duration of action of benzodiazepines include (a) age, (b)
underlying pathology, and (c) concurrent drug therapy.
14. A patient with hepatic and renal insufficiencies can have prolonged recovery from
benzodiazepines.
15. Diazepam has a rapid onset of action because of its high lipid solubility and ability to
traverse the blood-brain barrier relatively quickly. Onset is 3-5 minutes when the drug is
administered IV.
16. IV bolus at the start of infusion, followed by a series of smaller boluses with close titration to
produce the desired plasma concentration of the drug.
17. Acutely agitated patients are best treated with midazolam (Versed) because it has a rapid
onset and a short half-life.
18. Prolonged sedation with midazolam can occur from accumulation of the drug and its
metabolites in the peripheral tissues when it is used for longer than 48 hours.
19. Lorazepam (Ativan) is the drug of choice for use with ventilated patients for longer than 24
hours.
20. Flumazenil (Romazicon) reverses the effects of benzodiazepines; the most common side
effects of flumazenil include dizziness, panic attacks, and cardiac ischemia, and it may lead to

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WorkBook Answer Key 15-3

seizures in patients receiving long-term benzodiazepine or tricyclic antidepressant therapy.

21. (a) Lactic acidosis, (b) hyperosmolar coma, and (c) a reversible nephrotoxicity.
22. Neuroleptics
23. Haloperidol
24. (any of the following are a correct choice) Haloperidol has antidopaminergic and
anticholinergic effects. It can induce alpha blockade, lower the seizure threshold, and evoke
Parkinson-like symptoms (i.e., extrapyramidal effects, such as muscle rigidity, drowsiness, and
lethargy). Dose-dependent cardiac dysrhythmias, including QT prolongation and torsades de
pointes, have also been reported, particularly in patients receiving high-dose bolus IV
administration of haloperidol.
25. Propofol (Diprivan) causes a reduction in systemic vascular resistance with a concomitant
fall in blood pressure and bradycardia during the initial induction phase; it also reduces cerebral
blood flow and ICP.
26.
Advantages Disadvantages
Rapid onset, short duration of action Hypotension, dysrhythmias, bradycardia,
(makes rapid awakening possible for and elevated pancreatic enzymes.
neurological assessment), decreased ICP, Prolonged use has been associated with
clearance unaffected by renal or hepatic lactic acidosis and lipidemia in pediatric
dysfunction. patients.
27. (a) Morphine and (b) fentanyl.
28. (a) Relieve pain, (b) sedate, and (c) relieve anxiety.
29. (any of the following) Side effects of opioids include nausea, vomiting, reduced
gastrointestinal motility, respiratory depression, bradycardia, hypotension, myoclonus,
convulsions, histamine release, immunosuppression, and addiction.
30. The severity of these side effects depends on the dosage administered, the extent of the
patient’s illness, and the integrity of organ function (i.e., renal, hepatic, and hemodynamic
function).
31. Naloxone hydrochloride (Narcan)
32. Morphine’s effects on the CNS also include reduction of cerebral blood flow, intracranial
pressure, and cerebral metabolic activity; drowsiness and lethargy; miosis; and suppression of
the cough reflex.
33. Reduction of lower esophageal sphincter tone and propulsive peristaltic activity of the
intestine, which in turn leads to constipation. Morphine can increase the tone of the pyloric
sphincter and ultimately lead to nausea and vomiting by delaying the passage of contents through
the GI tract.
34. Morphine can alter vascular resistance by causing a decrease in sympathetic tone and an
increase in vagal tone. Reduction in vascular tone can lead to significant hypotension in patients
who rely on increased sympathetic tone to maintain blood pressure.
35. Fentanyl has minimal effects on the cardiovascular system and therefore should be used for
patients with an unstable hemodynamic status.
36. Morphine and propofol
37. Depolarizing NMBAs bind to acetylcholine receptors, causing prolonged depolarization of
the motor end plate. Nondepolarizing NMBAs cause paralysis by competitively inhibiting the
action of acetylcholine at the neuromuscular junction.
38. NMBAs are used (a) when patient-ventilator dyssynchrony cannot be corrected by adjusting

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WorkBook Answer Key 15-4

ventilator settings; (b) to facilitate less conventional mechanical ventilation strategies (e.g.,
inverse I:E ratios, high-frequency ventilation, permissive hypercapnia); (c) when dynamic
hyperinflation cannot be corrected; and (d) to reduce oxygen consumption and carbon dioxide
production.
39. To assess a patient’s depth of paralysis.
40. Two electrodes are placed on the skin along a nerve path, near a hand, foot, or facial nerve.
An electrical current consisting of four impulses is applied to the peripheral nerve over 2
seconds; the muscle contractions (twitches) produced provide information about the level of
paralysis.
41. One or two twitches when the train-of-four test is performed indicate that an adequate
amount of NMBA is being used.
42. Patients receiving an NMBA must also be given sedation, because NMBAs do not sedate the
individual.
43. Succinylcholine; onset is approximately 1 minute, and its duration of action is 5-10 minutes.
44. The most common side effects associated with succinylcholine include transient
hyperkalemia; cardiac dysrhythmias; anaphylactic reactions; prolonged apnea; postoperative
myalgias; increased intragastric, intracranial, and intraocular pressures; myoglobinuria; and
sustained skeletal muscle contraction. It may also precipitate malignant hyperthermia in
susceptible individuals.
45. Pancuronium (Pavulon)
46. Vecuronium bromide (Norcuron), atracurium besylate (Tracrium), and cisatracurium besylate
(Nimbex) are intermediate-duration, nondepolarizing NMBAs.
47. Prolonged paralysis after discontinuation of pancuronium can occur in patients with renal and
hepatic failure. The prolonged duration of action may be partially explained by the fact that it is
metabolized in the liver to an active 3-hydroxy metabolite that retains up to 50% of the activity
of the parent compound.
48. Atracurium
49. Atracurium
50. Atracurium and cisatracurium
51. Cisatracurium
52. (a) Tolerance, which may necessitate increasing the dosage, and (b) muscle weakness.

CRITICAL THINKING QUESTIONS

1. When an NMBA is used in a mechanically ventilated patient, the apnea alarm, low inspiratory
pressure alarm, low exhaled VT alarm, and low exhaled minute volume alarm should be set and
active. If a pulse oximeter is used continually, the low SpO2 alarm should be used.
2. Fentanyl (Sublimaze), a synthetic opioid, is the best choice for patients with asthma, because it
does not cause histamine release, as morphine does. Morphine is not recommended in patients
with asthma, because its mast cell–mediated histamine release may worsen bronchoconstriction.

CASE STUDY

1. NMBA
2. The RT should switch the patient to full ventilatory support before administering an NMBA,
because the patient’s diaphragm and accessory muscles will be paralyzed.

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WorkBook Answer Key 15-5

NBRC-STYLE QUESTIONS

1. B
2. A
3. C
4. D
5. C
6. B
7. C
8. A
9. D
10. A

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