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 | αα1 > 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 |
αα1 | 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 | αα1=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 needs approval from MICU leadership |
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 |
| Sedatives/Anxiolytics: | |||||||
|---|---|---|---|---|---|---|---|
| Drug | Dose | Class | Side effects | ||||
| Propofol | Infusion: 5 – 150 mcg/kg/min | General anesthetic (GABA R agonist) | 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 αα2 agonist | Hypotension, bradycardia | ||||
| Midazolam (Versed) | Push: 0.5 – 5 mg Infusion: 0.25 – 5 mg/h (no max dose) |
Benzodiazepine | Hypotension, risk of BNZ 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 | Hypotension, propylene glycol carrier - AGMA | ||||
| Ketamine | Push: 1-2mg/kg Infusion: 0.2mg/kg/hr, titrate by 0.1 q15min |
NDMA antagonist | Delirium/hallucination – use caution in patients with psychiatric hx, hypertension, tachycardia Pretreat with 0.4mg IV glycopyrrolate to avoid hyper-salivation |
||||
| Analgesic: | ||
|---|---|---|
| Drug | Dose | Side effects |
| Fentanyl | Push: 25 – 100 mcg Infusion: 25 – 400 mcg/h |
Hypotension, Serotonin syndrome, chest wall rigidity at high doses |
| Morphine | Push: 1 – 5 mg q1-2h prn Infusion: 1 – 5 mg/h |
Hypotension (profound), itching, constipation, HA; avoid in renal failure |
| Hydromorphone (Dilaudid) | Push: 0.25 – 1 q1-2h prn Infusion: 0.5 – 3 mg/h |
Hypotension, respiratory depression, itching |
| Anti-hypertensives | |||||
|---|---|---|---|---|---|
| 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/hr (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 E, 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 |
| Anti-Arrhythmics: | ||||
|---|---|---|---|---|
| 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 patients, 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 |