MICU/CCU Drips
Cairo De Souza
Most have order sets in Epic. Typically choose “Titration Allowed” in ICU.
Most pressors have risk of skin necrosis, peripheral/visceral ischemia. OK to start on unstable patient with peripheral IVs, but ideally most of these are run through central access.
MICU SOP - Infusing Vasoactive Medications Through a Peripheral IV.
Vasopressors/Inotropes
| Drug | Dose | Receptors | Indications | Considerations |
|---|---|---|---|---|
| Norepinephrine (Levophed) | 1-250 mcg/min | α1 > β1 | 1st line septic shock | Increases PVR when >15 (caution with RV dysfunction) |
| Phenylephrine (Neosynephrine) |
Bolus: 0.05-0.5 mg q 10-15 min Infusion: 40-400 mcg/min | α1 | Periprocedural hypotension (Neostick), patients with tachyarrhythmias, critical AS or HOCM with severe LVOT obstruction and shock, traumatic brain injury | Reflex bradycardia, can decrease CO, can increase PVR |
| Epinephrine | 1-40 mcg/min |
β1, β2 > α1 (low) α1 > β1, β2 (high) | Post cardiac arrest, anaphylaxis, severe septic shock, cardiogenic shock, bradycardia, severe asthma | Tachy-arrhythmias, can increase PVR |
| Vasopressin |
Usually 0.04 U/min Can see 0.06-0.08 in CCU | V1, V2, V3 | 2nd line septic shock, right heart failure, acute diabetes insipidus |
Hyponatremia, bradycardia, can decrease CO Minimal effect on PVR |
|
Angiotensin II (ANG II) *needs approval MICU leadership | 1.25-40 ng/kg/min | AT1 | Refractory vasodilatory shock |
Thrombosis: patient must have chemical DVT prophylaxis Arrhythmogenic Bronchospasm Contraindicated in HF, active bleed |
| Methylene Blue |
Bolus: 1-2 mg/kg over 20-60 min Scheduled: 100 mg over 6 h, x3d |
Electron carrier for Fe³⁺ → Fe²⁺ NO-cGMP inhibitor | Methemoglobinemia, ifosfamide-induced encephalopathy, refractory vasodilatory shock |
CNS depression, serotonin syndrome Contraindicated in G6PD deficiency |
| Dopamine | 2-20 mcg/kg/min | D1 (1-5 mcg) > β1 (5-10 mcg) > α1 (>10 mcg) | Hypotension, cardiogenic shock, high grade block/bradycardia |
Tachy-arrhythmias Contraindicated in pheochromocytoma |
| Dobutamine | 2.5-20 mcg/kg/min | β1 > β2 >> α1 | Cardiogenic shock |
Hypotension, vasodilation, tachyarrhythmias,
ventricular ectopy, tachyphylaxis Contraindicated in HOCM & severe AS |
| Milrinone | 0.125-0.75 mcg/kg/min | PDE-3 inhibitor | Cardiogenic shock, particularly if elevated PVR/pHTN |
Hypotension, vasodilation, ventricular ectopy,
tachyarrhythmias, renally cleared Contraindicated in HOCM & severe AS |
Sedatives/Anxiolytics
| Drug | Dose | Class | Metabolism | Side Effects |
|---|---|---|---|---|
| Propofol (Diprivan) | Infusion: 5–150 mcg/kg/min |
General anesthetic (GABA R agonist) |
Hepatic, Renal (minor) |
Severe hypotension, bradycardia, QT prolongation,
hypertriglyceridemia (leading to pancreatitis),
propofol infusion syndrome (rare)
Monitor for toxicity with q4 day TGs and CK |
| Dexmedetomidine (Precedex) | Infusion: 0.1–1.5 mcg/kg/hr | Central α2 agonist | Hepatic | Hypotension, bradycardia, tachyphylaxis, constipation, fevers |
| Midazolam (Versed) |
Push: 0.5–5 mg
Infusion: 0.25–5 mg/hr (no max dose) | Benzodiazepine |
Hepatic, renal, CYP3A4 | Hypotension, risk of BNZ withdrawal if used for long periods with sudden discontinuation, can have longer half-life/clearance in obese and cirrhotic patients (prolonged sedation) |
| Lorazepam (Ativan) |
Push: 0.5–10 mg
Infusion: 0.5–5 mg/hr (no max dose) | Benzodiazepine | Hepatic, renal |
Hypotension, propylene glycol carrier → AGMA
*cirrhosis minimally impacts clearance* |
Analgesics
| Drug | Dose | Metabolism | Side Effects |
|---|---|---|---|
| Fentanyl |
Push: 25–100 mcg Infusion: 25–400 mcg/hr | Hepatic | Hypotension, itching, constipation, HA, serotonin syndrome, chest wall rigidity at high doses |
| Morphine |
Push: 1–5 mg q1-2h prn Infusion: 1–5 mg/hr | Hepatic/Renal | Hypotension (profound), itching, constipation, HA; Avoid in renal failure |
| Hydromorphone (Dilaudid) |
Push: 0.25–1 mg q1-2h prn Infusion: 0.5–3 mg/hr | Hepatic | Hypotension, respiratory depression, itching |
Anti-Arrhythmics
| Drug | Dose | Indications | Side Effects | Comments |
|---|---|---|---|---|
| Adenosine | 6–12 mg IV rapid push and flush; may repeat ×2 | 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 → 1 mg/min × 6h → 0.5 mg/min × 18h (order set) |
VTach/VFib, AFib | Pulmonary, ophthalmic and thyroid toxicity with chronic use | Less hypotension than other agents, safe in heart failure. May chemically cardiovert patients, caution if off therapeutic AC. |
| Diltiazem (Cardizem) |
Push: 10–20 mg q15 min × 2
if no response
Infusion: 5–15 mg/h |
AFib, Aflutter, PSVT | Bradycardia, hypotension | Avoid use in patients with HFrEF |
| Lidocaine | ACLS: 1 mg/kg × 1 |
Anti-Arrhythmics
| Drug | Class/MOA | Dose | Indications | Side Effects | Comments |
|---|---|---|---|---|---|
| Esmolol | Beta blocker |
Bolus: 1 mg/kg over 30s
Infusion: 50–300 mcg/kg/min | Aortic dissection, HTN emergency, AFib/flutter w/ RVR | Bradycardia, hypotension | Titrate to desired BP or HR. Caution in HFrEF, asthma, pheo |
| Nicardipine | CCB | Infusion: 5–15 mg/h | HTN emergency, CVA | Tachycardia, hypotension | Titrate to desired BP; avoid in HFrEF, AS, & HOCM |
| Nitroprusside | Metabolized to NO; a vasodilator effect (arterial roughly = venous) | Infusion: 0.3 mcg/kg/min; titrate q2 min to max 10 mcg/kg/min | HTN emergency, flash pulmonary edema, HFrEF for afterload reduction, valvular cardiogenic shock | Hypotension, cyanide/thiocyanate toxicity, methemoglobinemia, increased ICP |