MICU/CCU Drips¶

Patrick Barney

Most have order sets in Epic. Typically choose Titration Allowed” in ICU

Vasopressors¶

Drug	Dose	Receptors	Indications	Considerations
Norepinephrine (Levophed)	1 – 100 mcg/min	α1 > β1	1st line septic shock	Peripheral ischemia, skin necrosis
Phenylephrine (Neosynephrine)	Bolus: 0.05 – 0.5 mg q 10-15 min Infusion: 40-360 mcg/min	α1	Periprocedural hypotension (Neostick), pts w/ tachyarrhythmias, Critical AS or HOCM with severe LVOT obstruction and shock	Reflex bradycardia, Peripheral ischemia, skin necrosis
Epinephrine	1 – 40 mcg/min	α1=β1=β2	Post PEA arrest, Anaphylaxis, Septic shock (severe), Cardiogenic shock	Tachy-arrhythmias, Peripheral ischemia, skin necrosis
Vasopressin	0.04 U/min (no titration);	V1, V2, V3	2nd line septic shock, Right heart failure	Hyponatremia, Bradycardia
ANG II	20 – 40 ng/kg/min	ANG II	Refractory vasodilatory shock	Thrombosis - pt MUST have chemical DVT ppx. Contraindicated in heart failure
Dopamine	2 – 20 mcg/kg/min	Dopamine (1-5 mcg) > β1 (5-10 mcg) >α1 (>10mcg)	Hypotension, Cardiogenic shock	Tachy-arrhythmias, Peripheral ischemia, skin necrosis
Dobutamine	2.5 – 20 mcg/kg/min	β1 >>> β2	Cardiogenic shock	Vasodilation Hypotension, Tachycardia, Tachyphylaxis
Milrinone	0.375 – 0.75 mcg/kg/min	PDE-3	Cardiogenic shock	Hypotension, Renally cleared

Drug	Dose	Class	Metabolism	Side Effects
Propofol	Infusion: 5 – 150 mcg/kg/min	General anesthetic (GABA R agonist)	Hepatic, Renal (minor)	Severe hypotension, bradycardia, hypertriglyceridemia, propofol infusion syndrome (rare) Monitor for toxicity with q4 day TGs and CK
Dexmedetomidine (Precedex)	Infusion: 0.1 – 1.5 mcg/kg/h	Central α2 agonist	Hepatic	Hypotension, bradycardia
Midazolam (Versed)	Push: 0.5 – 5 mg Infusion: 0.25 – 5 mg/h (no max dose)	Benzodiazepine	Hepatic & Renal	Hypotension, risk of benzodiazepine withdrawal if used for long periods with sudden discontinuation
Lorazepam (Ativan)	Push: 0.5 – 10 mg Infusion: 0.5 – 5 mg/h (no max dose)	Benzodiazepine	Hepatic	Hypotension. Propylene glycol carrier – AGMA
Ketamine	Push: 1-2 mg/kg Infusion: 0.2 mg/kg/h, titrate by 0.1 q15min	NDMA antagonist	Hepatic	Delirium/hallucination – use caution in patients with psychiatric history, hypertension, tachycardia Pretreat with 0.4 mg IV glycopyrrolate to avoid hyper-salivation

Drug	Dose	Metabolism	Side effects
Fentanyl	Push: 25 – 100 mcg Infusion: 25 – 400 mcg/h	Hepatic	Hypotension, Serotonin syndrome, chest wall rigidity at high doses
Morphine	Push: 1 – 5 mg q1-2h prn Infusion: 1 – 5 mg/h	Hepatic/Renal	Hypotension (profound), itching, constipation, HA; avoid in renal failure
Hydromorphone (Dilaudid)	Push: 0.25–1mg q1-2h prn Infusion: 0.5–3 mg/h	Hepatic	Hypotension, respiratory depression, itching

Drug	Dose	Indications	Side effects	Comments
Adenosine	6 – 12 mg IV rapid push and flush; may repeat x2	PSVT conversion	Complete AV nodal blockade	10 second half-life Must have continuous EKG/tele monitor
Amiodarone	ACLS: 300 mg IV push Non-emergent: 150 mg over 10 min then 0.5 mg/min	Vtach/Vfib, Afib	Pulm, ophthalmic and thyroid toxicity w/ chronic use	Less hypotension than other agents, safe in heart failure. May chemically cardiovert pts, caution if off therapeutic AC
Diltiazem	Push: 10 – 20 mg q15 min x 2 if no response Infusion: 5 – 15 mg/h	Afib, Aflutter, PSVT	Bradycardia, hypotension	Avoid use in pts with HfrEF
Lidocaine	ACLS: 1 mg/kg x 1 Infusion: 1 – 4 mg/min	Vtach	Bradycardia, Heart block	Avoid use in liver failure/ Okay for HfrEF. Often 1st line CCU med for VT/ May need to check levels if using for longer than 24 hours
Procainamide	15 mg/kg over 30 min then 1 – 6 mg/min	Vtach, refractory afib	Bradycardia, hypotension	Drug-induced lupus, cytopenias

Drug	Class/MOA	Dose	Indications	Side effects	Comments
Esmolol	Beta blocker	Bolus: 1mg/kg over 30s Infusion: 50-300mcg/kg/min (max 300)	Aortic dissection, HTN emergency	Bradycardia, hypotension	Titrate to desired BP or HR. Caution in HfrEF
Nicardipine	CCB	Infusion: 5-15mg/h (max 15)	HTN emergency	Bradycardia, hypotension	Titrate to desired BP, avoid in HfrEF
Nitroprusside	Metabolized to NO → vasodilatory effect (arterial roughly = venous)	Infusion: 0.3mcg/kg/min; titrate q2min to max 10mcg/kg/min	HTN emergency, flash pulmonary edema, HfrEF for afterload reduction	Hypotension, cyanide toxicity	Contraindicated in hepatic and renal failure
Nitroglycerin	NO mediated venous > arterial vasodilation	Infusion: start 0.25mcg/kg/min, titrate by 1mcg/kg/min q15min (max 10mcg/kg/min)	Refractory angina, flash pulmonary edema, HTN emergency	Hypotension, headache, palpitations	Contraindicated in severe RHF and concurrent use of PDE-5 inhibitor