High-Risk Medications

The Quality System Regulation is introduced for medical devices, requiring developers of high-risk devices to apply design controls. 

Patients should be classified as low-, moderate-, or at high-risk depending on their medical condition and presence of risk factors... 

The serum creatinine is measured to identify patients who may need dosing adjustments for some medications, as well as those who are at high risk of morbidity and mortality. 

In general, early pharmacotherapy of NSTE ACS (Fig. 5-3) is similar to that of STE ACS with three exceptions (1) fibrinolytic therapy is not administered (2) glycoprotein Ilb/IIIa receptor blockers are administered to high-risk patients for medical therapy as well as to PCI patients and (3) at this time, there are no standard quality indicators for patients with NSTE ACS who are not diagnosed with MI. 

Upon stabilization, placement of a pulmonary artery (PA) catheter may be indicated based on the need for more extensive cardiovascular monitoring than is available from non-invasive measurements such as vital signs, cardiac rhythm, and urine output.9,10 Key measured parameters that can be obtained from a PA catheter are the pulmonary artery occlusion pressure, which is a measure of preload, and CO. From these values and simultaneous measurement of HR and blood pressure (BP), one can calculate the left ventricular SV and SVR.10 Placement of a PA catheter should be reserved for patients at high risk of death due to the severity of shock or preexisting medical conditions such as heart failure.11 Use of PA catheters in broad populations of critically ill patients is somewhat controversial because clinical trials have not shown consistent benefits with their use.12-14 However, critically ill patients with a high severity of illness may have improved outcomes from PA catheter placement. It is not clear why this was... 

A number of medications have been studied to alleviate symptoms of stimulant withdrawal and the intense craving that may accompany it, but inconsistent results across controlled trials preclude any recommendations for their routine use. Patients with stimulant use disorders should be referred to substance abuse treatment because of the high risk for continued use either during or immediately following stimulant withdrawal. 

In order to achieve a goal blood pressure, lifestyle modifications, including diet, exercise, sodium restriction, and smoking cessation, are recommended.63 Unfortunately, lifestyle modifications alone often are inadequate to control HTN in this high-risk population, and antihypertensive medications usually are needed. 

Medical emergency due to high risk of vision loss. 

Patient symptoms, past medical history, ECG, and troponin or CK-MB determinations are used to stratify patients into low, medium, or high risk of death or MI or likelihood of needing urgent coronary angiography and percutaneous coronary intervention (PCI). 

In patients with NSTE ACS, clinical practice guidelines recommend either PCI or coronary artery bypass grafting revascularization as an early treatment for high-risk patients, and that such an approach also be considered for moderate-risk patients. An early invasive approach results in fewer Mis, less need for revascularization procedures over the next year after hospitalization, and lower cost than the conservative medical stabilization approach. 

Administration of tirofiban or eptifibatide is recommended for high-risk NSTE ACS patients as medical therapy without planned revascularization. 

When treating anxiety one should of course first treat any reversible medical condition. When pharmacological treatment is necessary SSRI is most often drug of choice. Selective serotonin reuptake inhibitors are both effective and safe. Benzodiazepines that have been widely used are drugs with a relative high risk of adverse effects (see Chapter 4). Risks for dependence and abuse must always be considered for benzodiazepines. 

Since the elderly use many drugs they are at high risk for medication errors and also for medication injuries, causing waste of resources and human suffering... 

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