The therapist is at the bedside of a mechanically ventilated patient with renal disease. Patient-ventilator asynchrony is present. The patient has received analgesics, benzodiazepines, and haloperidol to no avail. The physician suggests using atracurium. How should the therapist respond to this suggestion?

A. Agree to the administration of the atracurium.
B. Refrain from using atracurium because it is toxic to the kidneys and liver.
C. Suggest that vecuronium be administered instead.
D. Suggest that any aminosteroid would be suitable in this situation.

?ANS: A
A. Correct response: In patients with renal disease, caution is warranted in the use of aminosteroids (pancuronium, vecuronium, and rocuronium) because clearance can be greatly reduced and duration prolonged. Similar caution for this class is indicated in patients with cirrhosis. Vecuronium, a benzylisoquinolinium, has been reported to be the most associated with prolonged duration of action after discontinuation and should be avoided in these patients. Atracurium and cisatracurium are preferred agents in these patients because their clearance is not affected by real or hepatic dysfunction.
B. Incorrect response: Atracurium is preferred in this case.
C. Incorrect response: Vecuronium is contraindicated in this situation.
D. Incorrect response: Aminosteroids are not advisable for patients with liver and/or renal disease.