NURS 6521 - Discussion Week 1

Instructions:

Rea

d

a selection of your colleague

and respond

by suggesting additional patient

factors that might have interfered with the pharmacokinetic and pharmacodynamic

processes of the patients they described. In addition, suggest how the personalized

plan of care might change if the age of the patient were di

fferent and/or if the patient

had a comorbid condition, such as renal failure, heart failure, or liver failure

**minimum of three

(3)

scholarly references are

required for each reply

cited

within the body of the reply & at the end

**

Reply

#

2

Angela

David

I work in a busy car

diovascular intensive care unit (CVICU), and of the many cases that I could reflect upon,

one in particular stands out.

I once cared for a75

-

year

-

old woman who required an emergency repair of a type

A aortic dissection.

Her case was complex and required

extensive time on cardiopulmonary bypass and total

circulatory arrest.

She bled postoperatively, was subsequently hypotensive,

and required transfusion of

multiple products.

Prior to surgery, she had a history of renal insufficiency.

Post operatively,

she went into

acute renal failure, required continuous renal replacement therapy(CRRT) and remained intubated for five

days.

Due to the fact that she remained intubated and unstable, she was sedated on a combination of IV

propofol and morphine bolus doses

for pain management.

When the patient became hemodynamically stable

and attempts were made to reduce sedation in order to assess her neurological status, the patient was somnolent,

and remained so after sedation was completely discontinued.

There a

re a number of pharmacokinetic changes that occur with aging, such as reduction in hepatic

metabolism and reduction in renal excretion, which are both important considerations in this case(Linnebur and

Ruscin, 2021).

One pharmacodynamic change in the elde

rly, particularly related to opioid analgesics, is

increased drug sensitivity(Bath, et al, 2011).

Considering these factors, along with the fact that this patient was

in acute renal failure, morphine, which is metabolized by the liver and primarily excret

ed by the kidneys, was

not the best choice for this patient and likely led to increased sedation and depressed respiratory drive. Upon

reflection, fentanyl, a shorter acting opioid, might have been a safer choice for this patient.

References

Linnebur, S., and Ruscin, J., (2021). Pharmacokinetics in Older Adults,

Merck

Manual.

https://www.merckmanuals.com/profession

al/geriatrics/drug

-

therapy

-

in

-

older

-

adults/pharmacokinetics

-

in

-

older

-

adults

Bath,S., Blythe, F.,

Couteur, D., Gibson, S., Hilmer, S., McLachlan, A., and Naganathan, V., (2011). Clinical pharmacology of

analgesic medicines in older people: impact of frailt

y and cognitive impairment

, Br J Clin Pharmacol

71(3):351

-

364. Doi:

10.1111/j.1365

-

2125.2010.03847.x

Instructions:

Read a selection of your colleague and respond by suggesting additional patient

factors that might have interfered with the pharmacokinetic and pharmacodynamic

processes of the patients they described. In addition, suggest how the personalized

plan of care might change if the age of the patient were different and/or if the patient

had a comorbid condition, such as renal failure, heart failure, or liver failure

**minimum of three (3) scholarly references are required for each reply cited

within the body of the reply & at the end**

Reply # 2

Angela David

I work in a busy cardiovascular intensive care unit (CVICU), and of the many cases that I could reflect upon,

one in particular stands out. I once cared for a75-year-old woman who required an emergency repair of a type

A aortic dissection. Her case was complex and required extensive time on cardiopulmonary bypass and total

circulatory arrest. She bled postoperatively, was subsequently hypotensive, and required transfusion of

multiple products. Prior to surgery, she had a history of renal insufficiency. Post operatively, she went into

acute renal failure, required continuous renal replacement therapy(CRRT) and remained intubated for five

days. Due to the fact that she remained intubated and unstable, she was sedated on a combination of IV

propofol and morphine bolus doses for pain management. When the patient became hemodynamically stable

and attempts were made to reduce sedation in order to assess her neurological status, the patient was somnolent,

and remained so after sedation was completely discontinued.

There are a number of pharmacokinetic changes that occur with aging, such as reduction in hepatic

metabolism and reduction in renal excretion, which are both important considerations in this case(Linnebur and

Ruscin, 2021). One pharmacodynamic change in the elderly, particularly related to opioid analgesics, is

increased drug sensitivity(Bath, et al, 2011). Considering these factors, along with the fact that this patient was

in acute renal failure, morphine, which is metabolized by the liver and primarily excreted by the kidneys, was

not the best choice for this patient and likely led to increased sedation and depressed respiratory drive. Upon

reflection, fentanyl, a shorter acting opioid, might have been a safer choice for this patient.

References

Linnebur, S., and Ruscin, J., (2021). Pharmacokinetics in Older Adults, Merck

Manual. https://www.merckmanuals.com/professional/geriatrics/drug-therapy-in-older-adults/pharmacokinetics-in-older-

adults

Bath,S., Blythe, F., Couteur, D., Gibson, S., Hilmer, S., McLachlan, A., and Naganathan, V., (2011). Clinical pharmacology of

analgesic medicines in older people: impact of frailty and cognitive impairment, Br J Clin Pharmacol 71(3):351-364. Doi:

10.1111/j.1365-2125.2010.03847.x