Mukherjee_Interventional Cardiology Board Review, 4e

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7 Antiarrhythmics, Inotropes, Sedatives, and Lipid-Lowering Agents

to extubation and ICU length of stay. The CPOT score of 0 indicates adequate analgesia, so the fentanyl dose can be maintained at the current infusion rate to maintain pain control. A RASS score of − 3 is indicative of deep sedation; the goal RASS for light sedation is 0 to − 2. There fore, the midazolam infusion rate should be de creased to achieve light sedation. 7.29 Answer B. Dexmedetomidine is recommended in patients with ongoing delirium that prevents ventilator weaning or extubation, per the Clini cal Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delir ium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Benzodiazepines, such as midazolam, are a known risk factor for delirium and should be minimized or avoided, if pos sible, to decrease the risk of delirium and pre vent worsening delirium. Atypical antipsychotic medications (ie, quetiapine) and haloperidol are not recommended for routine use to treat

delirium due to lack of clinical benefit, unless the patient experiences significant psychologi cal distress (eg, fearfulness, hallucinations). Ad equate analgesia is appropriate in patients with delirium, and fentanyl should be maintained for analgesia. 7.30 Answer A. Morphine is associated with de layed absorption of clopidogrel, ticagrelor, and prasugrel and a prolonged duration of high residual platelet reactivity. The mechanism of the drug-drug interaction is hypothesized to be secondary to delayed gastric emptying and a subsequent delayed absorption of oral P2Y12 inhibitors; each of the P2Y12 inhibitors is almost completely absorbed in the intestine. The clini cal effect of the interaction between morphine and oral P2Y12 inhibitors has not been con firmed with prospective, randomized controlled trials, although there may be an association be tween morphine use and worse cardiovascular outcomes in analyses of large registries.

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