Adult dosing for study purposes. Verify every dose against your institution's references and the package insert before clinical use. Weight-based doses use actual body weight unless noted; adjust for renal/hepatic function.
Vasopressors & inotropes
| Drug | Dose | Pearls |
|---|---|---|
| Norepinephrine | 0.01–0.5 mcg/kg/min (start 0.05–0.1); doses >1 mcg/kg/min used in refractory shock | First-line in septic and most undifferentiated shock. α₁ ≫ β₁. Add vasopressin at ~0.25–0.5 mcg/kg/min. |
| Vasopressin | 0.03 units/min fixed (range 0.01–0.04) | Catecholamine-sparing second agent; not titrated. V₁ receptor; no β effect. Watch for digital/mesenteric ischemia. |
| Epinephrine | Infusion 0.01–0.5 mcg/kg/min · Arrest 1 mg IV/IO q3–5 min · Anaphylaxis 0.3–0.5 mg IM (1 mg/mL), repeat q5–15 min | Third-line in septic shock; first-line in anaphylaxis and post-cardiotomy low output. Raises lactate (β₂) — lactate less reliable. |
| Phenylephrine | Bolus 50–200 mcg IV · Infusion 0.1–3 mcg/kg/min (10–200 mcg/min) | Pure α₁. Useful in tachyarrhythmia-limited hypotension, HOCM, aortic stenosis. Reflex bradycardia; may lower CO. |
| Dopamine | 2–20 mcg/kg/min (β at 5–10, α >10) | More arrhythmias than norepinephrine (SOAP II); reserved for bradycardic hypotension. "Renal-dose" dopamine has no benefit. |
| Dobutamine | 2.5–20 mcg/kg/min | β₁ inotrope with β₂ vasodilation; can drop MAP. Cardiogenic shock / low CO with adequate MAP. Tachyphylaxis after 48–72 h. |
| Milrinone | 0.125–0.75 mcg/kg/min (bolus 50 mcg/kg rarely used in ICU) | PDE-3 inhibitor: inotrope + vasodilator; RV failure, pulmonary HTN, β-blocked patients. Renally cleared — reduce dose in AKI; long half-life. |
| Angiotensin II (Giapreza) | Start 20 ng/kg/min, titrate q5 min; max 80 ng/kg/min first 3 h, then 1.25–40 ng/kg/min | Refractory distributive shock (ATHOS-3). Increased VTE — anticoagulate. Consider in ACE-inhibitor overdose/vasoplegia. |
| Isoproterenol | 2–10 mcg/min (0.01–0.2 mcg/kg/min) | Pure β agonist: bradycardia/heart block bridge to pacing, torsades. Vasodilates. |
| Methylene blue | 1–2 mg/kg IV over 15–30 min (± 0.5 mg/kg/h) | Vasoplegia (post-bypass, refractory septic shock): inhibits NO/guanylate cyclase. Contraindicated with SSRIs (serotonin syndrome) and G6PD deficiency. |
| Hydroxocobalamin | 5 g IV over 15 min | Also used off-label for vasoplegia (NO scavenging) and is the cyanide antidote. |
| Source: Surviving Sepsis Campaign 2021; SCCM/ACCM vasopressor reviews; ATHOS-3 (NEJM 2017); SOAP II (NEJM 2010); AHA ACLS 2020. | ||
Antihypertensives, vasodilators & antiarrhythmics
| Drug | Dose | Pearls |
|---|---|---|
| Nicardipine | Start 5 mg/h; ↑ 2.5 mg/h q5–15 min; max 15 mg/h | Dihydropyridine CCB. Hypertensive emergency, aortic dissection (after β-blockade), ICH/SAH BP control. Reflex tachycardia; long half-life once loaded. |
| Clevidipine | Start 1–2 mg/h; double q90 s; usual 4–6 mg/h; max 32 mg/h (≤21 mg/h avg per 24 h) | Ultra-short (1 min) lipid emulsion CCB. Contraindicated in soy/egg allergy, severe aortic stenosis; caution in pancreatitis/hyperlipidemia. |
| Esmolol | 500 mcg/kg bolus over 1 min, then 50–300 mcg/kg/min | Ultra-short β₁ blocker (t½ 9 min). Aortic dissection first (HR <60, SBP 100–120), thyroid storm, perioperative tachycardia. |
| Labetalol | 10–20 mg IV over 2 min, repeat/double q10 min (max 300 mg cumulative); infusion 0.5–2 mg/min | α₁ + β blocker (1:7). Pregnancy, stroke BP targets, aortic injury. Avoid in asthma, cocaine, heart block. |
| Hydralazine | 10–20 mg IV q4–6 h | Direct arteriolar dilator; unpredictable, reflex tachycardia — less favored in ICU titration. |
| Nitroglycerin | 5–200 mcg/min (up to 400); SL 0.4 mg | Venodilator: ACS, pulmonary edema (high dose), hypertensive emergency with heart failure. Tolerance at 24–48 h; avoid with PDE-5 inhibitors and RV infarction. |
| Nitroprusside | 0.3–0.5 mcg/kg/min, titrate to max 10 mcg/kg/min (limit 2 mcg/kg/min if prolonged) | Arterial + venous dilator; cyanide/thiocyanate toxicity with high dose, renal failure, >48–72 h. Raises ICP. |
| Amiodarone | Arrest: 300 mg IV push, then 150 mg · Stable VT/AF: 150 mg over 10 min, then 1 mg/min × 6 h, 0.5 mg/min × 18 h (PO 400 mg TID load) | Class III (multi-channel). Hypotension with bolus (solvent). Pulmonary, thyroid, hepatic toxicity; ↑ warfarin/digoxin levels; QT prolongation. |
| Lidocaine | 1–1.5 mg/kg IV bolus (repeat 0.5–0.75 mg/kg), then 1–4 mg/min | Alternative to amiodarone in VF/pVT. Neurotoxicity (seizures) especially with hepatic dysfunction or low CO. |
| Adenosine | 6 mg rapid IV push + flush; then 12 mg × 2 if needed | Stable narrow-complex SVT. Half-life <10 s; central line: use 3 mg. Avoid in WPW with AF, transplant hearts (↓ dose), severe asthma. |
| Diltiazem | 0.25 mg/kg IV (≈20 mg) over 2 min; repeat 0.35 mg/kg (≈25 mg) in 15 min; infusion 5–15 mg/h | Rate control in AF/flutter with preserved EF. Avoid in reduced EF, WPW, hypotension. |
| Metoprolol | 2.5–5 mg IV q5 min × 3; PO 25–100 mg q6–12 h | Rate control; postoperative AF; ACS. Avoid in acute decompensated HF, shock, bronchospasm. |
| Digoxin | Load 0.5 mg IV, then 0.25 mg q6 h × 2 (total 0.75–1.5 mg); maintenance 0.125–0.25 mg/day | Rate control when hypotensive/low EF (slow onset). Renally cleared; toxicity with hypokalemia, hypomagnesemia; DigiFab for toxicity. |
| Procainamide | 20–50 mg/min IV until arrhythmia stops, hypotension, QRS ↑ 50%, or 17 mg/kg; then 1–4 mg/min | Stable wide-complex tachycardia and pre-excited AF (WPW). Hypotension, lupus-like syndrome. |
| Magnesium sulfate | Torsades: 2 g IV over 1–2 min (arrest) or 15 min; repletion 1–4 g IV over 1–4 h | Target Mg >2 mg/dL in arrhythmia. Also eclampsia (4–6 g load, 1–2 g/h) and severe asthma (2 g). |
| Atropine | 1 mg IV q3–5 min (max 3 mg) | Symptomatic bradycardia. Ineffective in transplanted hearts and infranodal block — go to pacing/epinephrine/dopamine. |
| Source: AHA ACLS Guidelines 2020; ACC/AHA Atrial Fibrillation Guideline 2023; ACC/AHA Hypertension Guideline 2017; Lexicomp/package inserts. | ||
Sedation, analgesia & induction
| Drug | Dose | Pearls |
|---|---|---|
| Propofol | Sedation 5–50 mcg/kg/min (max ~80) · Induction 1–2.5 mg/kg (0.5–1 in shock/elderly) | GABA. Hypotension, hypertriglyceridemia (check TG q3–4 days; 1.1 kcal/mL), pancreatitis, PRIS (>4 mg/kg/h × >48 h: acidosis, bradycardia, rhabdo). Preferred for light sedation, neuro exams. |
| Dexmedetomidine | 0.2–1.5 mcg/kg/h (optional load 1 mcg/kg over 10 min — usually omitted) | α₂ agonist; arousable sedation, no respiratory depression, analgesic-sparing. Bradycardia and hypotension; not for deep sedation alone. Useful for delirium/withdrawal and extubation. |
| Midazolam | Bolus 0.5–2 mg (up to 0.05 mg/kg) · Infusion 0.01–0.1 mg/kg/h (1–7 mg/h) | Benzodiazepine; accumulates with renal failure, obesity, CYP3A4 inhibitors → prolonged sedation, delirium. Reserve for seizures, withdrawal, deep sedation needs. |
| Lorazepam | 0.5–2 mg IV q2–6 h; infusion 0.5–2 mg/h (rare) | Propylene glycol toxicity (osmolar gap, lactic acidosis) at high infusion rates. Status epilepticus 0.1 mg/kg (max 4 mg/dose). |
| Ketamine | Induction 1–2 mg/kg IV (4–5 mg/kg IM) · Analgosedation 0.1–0.5 mg/kg/h · Sub-dissociative analgesia 0.1–0.3 mg/kg | NMDA antagonist: preserves respiratory drive and BP (catecholamine release; can drop BP in catecholamine-depleted shock). Bronchodilator. Emergence phenomena, hypersalivation. ICP concern largely disproven. |
| Etomidate | 0.3 mg/kg IV induction | Hemodynamically neutral; adrenal suppression (11β-hydroxylase) 24–48 h after a single dose; myoclonus. No infusion. |
| Fentanyl | Bolus 25–100 mcg IV q30–60 min · Infusion 25–200 mcg/h (0.7–10 mcg/kg/h) | Rapid onset, no active metabolites, safe in renal failure; lipophilic — accumulates with prolonged infusion. Chest wall rigidity with large rapid boluses. Serotonin syndrome with SSRIs/linezolid. |
| Hydromorphone | 0.2–1 mg IV q1–3 h · Infusion 0.5–3 mg/h · PCA 0.2 mg q6–10 min | ~7× morphine potency; fewer active metabolites than morphine — preferred in renal impairment among the morphinans. |
| Morphine | 2–5 mg IV q1–2 h · Infusion 2–10 mg/h · PCA 1 mg q6–10 min | Histamine release (hypotension, bronchospasm); morphine-6-glucuronide accumulates in renal failure → prolonged sedation. Avoid in AKI. |
| Remifentanil | 0.05–0.2 mcg/kg/min (no bolus in ICU) | Esterase-metabolized, context-insensitive half-life (3–10 min) — ideal for frequent neuro checks; hyperalgesia on abrupt discontinuation. |
| Acetaminophen | 1 g IV/PO q6 h (max 4 g/day; 2–3 g/day in liver disease, low weight, alcohol use) | Multimodal foundation; IV offers no clear advantage over PO/PR if gut works. Hypotension reported with IV in critically ill. |
| Ketorolac | 15–30 mg IV q6 h (15 mg if >65 y, <50 kg, or CrCl reduced); max 5 days | NSAID: AKI, bleeding, GI ulceration; avoid in hypovolemia, AKI, anastomotic concerns per surgeon preference. |
| Gabapentin | 100–300 mg PO TID, titrate (renal adjust) | Neuropathic pain, opioid-sparing; sedation, respiratory depression with opioids. |
| Haloperidol | 0.5–5 mg IV/IM q30 min–6 h PRN | Agitation; no benefit on delirium duration (MIND-USA). QTc prolongation, EPS, NMS. Check QTc >500 ms. |
| Quetiapine | 25–50 mg PO q12 h, titrate to 200 mg/day | Off-label for ICU delirium; sedating, orthostasis, QTc. Stop at discharge. |
| Naloxone | 0.04–0.4 mg IV, titrate q2–3 min to 2 mg (0.4–2 mg for apnea); infusion ⅔ of effective bolus per hour | Opioid reversal; precipitates withdrawal — use low doses in opioid-tolerant. Duration 30–90 min, shorter than most opioids. |
| Flumazenil | 0.2 mg IV over 30 s; repeat 0.2 mg q1 min to 1 mg | Benzodiazepine reversal; seizures in chronic benzodiazepine users, TCA co-ingestion — rarely used in ICU. |
| Source: SCCM PADIS Guidelines 2018 (Devlin et al., Crit Care Med); SCCM Clinical Practice Guidelines for Sustained NMB 2016; Lexicomp; Marino's The ICU Book, 4th ed. | ||
Neuromuscular blockers & reversal
| Drug | Dose | Pearls |
|---|---|---|
| Succinylcholine | 1–1.5 mg/kg IV (3–4 mg/kg IM); onset 45–60 s, duration 5–10 min | Depolarizing. K⁺ rises ~0.5 mEq/L; contraindicated with hyperkalemia risk: burns/crush/denervation/immobilization >24–72 h (up to 1–2 years), neuromuscular disease, malignant hyperthermia history. Bradycardia (children, repeat dose). Prolonged with pseudocholinesterase deficiency. |
| Rocuronium | RSI 1–1.2 mg/kg (onset 60 s); intubation 0.6 mg/kg; infusion 8–12 mcg/kg/min (0.3–0.6 mg/kg/h) | Aminosteroid; hepatic elimination — prolonged in hepatic failure. Reversible with sugammadex. Preferred RSI alternative to succinylcholine. |
| Vecuronium | 0.08–0.1 mg/kg bolus; infusion 0.8–1.7 mcg/kg/min | Aminosteroid; hepatic + renal (active 3-desacetyl metabolite accumulates in renal failure). Sugammadex-reversible. |
| Cisatracurium | 0.1–0.2 mg/kg bolus; infusion 1–3 mcg/kg/min (ARDS trials: 37.5 mg/h fixed × 48 h) | Benzylisoquinolinium; Hofmann elimination (organ-independent) — agent of choice in hepatic/renal failure. Laudanosine metabolite (seizures, theoretical). Not reversible with sugammadex. |
| Sugammadex | 2 mg/kg (TOF ≥2 twitches) · 4 mg/kg (deep block, PTC 1–2) · 16 mg/kg (immediate reversal after 1.2 mg/kg rocuronium) | Binds rocuronium > vecuronium; not cisatracurium/succinylcholine. Anaphylaxis, bradycardia; reduces hormonal contraceptive efficacy 7 days; caution CrCl <30. |
| Neostigmine + glycopyrrolate | Neostigmine 0.03–0.07 mg/kg (max 5 mg) with glycopyrrolate 0.2 mg per 1 mg neostigmine (or atropine 0.4 mg/mg) | Reverse only when TOF ≥2–4 twitches; ceiling effect. Also neostigmine 2–2.5 mg IV for Ogilvie syndrome (with atropine at bedside). |
| Dantrolene | 2.5 mg/kg IV, repeat q5–10 min to effect (cumulative up to 10 mg/kg+); then 1 mg/kg q4–6 h × 24–48 h | Malignant hyperthermia (Ryanodex 250 mg vials dissolve faster). Also NMS adjunct. Hepatotoxicity; avoid with CCBs (hyperkalemia). |
| Source: SCCM Guidelines for Sustained NMB in the Adult Critically Ill Patient 2016; ACURASYS (NEJM 2010); ROSE (NEJM 2019); MHAUS; Miller's Anesthesia. | ||
Anticoagulation, reversal & hemostasis
| Drug | Dose | Pearls |
|---|---|---|
| Unfractionated heparin | Prophylaxis 5,000 U SC q8–12 h · Therapeutic (VTE) 80 U/kg bolus, 18 U/kg/h; (ACS) 60 U/kg (max 4,000), 12 U/kg/h · target aPTT 1.5–2.5× or anti-Xa 0.3–0.7 | Preferred when CrCl <30 or reversal may be needed. HIT (5–10 days; 4T score). Reverse with protamine. |
| Enoxaparin | Prophylaxis 40 mg SC daily (30 mg q12h trauma/ortho/BMI >40; anti-Xa 0.2–0.4 goal) · Therapeutic 1 mg/kg q12 h (1.5 mg/kg daily) · CrCl <30: 30 mg daily / 1 mg/kg daily | Renal clearance; anti-Xa monitoring in renal failure, obesity, pregnancy. Partially reversed by protamine (1 mg per 1 mg within 8 h; 0.5 mg/mg after). |
| Fondaparinux | 2.5 mg SC daily (prophylaxis); 5/7.5/10 mg daily by weight (<50 / 50–100 / >100 kg) | Option in HIT. Contraindicated CrCl <30 and <50 kg. No reversal agent (rFVIIa anecdotal). |
| Argatroban | 2 mcg/kg/min; 0.5 mcg/kg/min in hepatic dysfunction, critical illness, post-cardiac surgery; aPTT 1.5–3× baseline | Direct thrombin inhibitor for HIT; hepatic clearance. Raises INR — target INR >4 on combined therapy when bridging to warfarin, then recheck 4–6 h after stopping. |
| Bivalirudin | 0.15–0.2 mg/kg/h (HIT, off-label); PCI 0.75 mg/kg bolus + 1.75 mg/kg/h; ECMO 0.03–0.05 mg/kg/h | DTI; enzymatic + renal clearance (reduce with CrCl <30). Short half-life (25 min). Stasis clotting in circuits. |
| Warfarin | 2.5–10 mg PO daily; INR 2–3 (2.5–3.5 mechanical mitral) | Vitamin K antagonist; skin necrosis (protein C) — overlap with heparin ≥5 days. Many interactions. |
| Apixaban / Rivaroxaban | Apixaban 10 mg BID × 7 d then 5 mg BID (VTE); 2.5–5 mg BID (AF) · Rivaroxaban 15 mg BID × 21 d then 20 mg daily | Factor Xa inhibitors; reverse with andexanet alfa or 4F-PCC 25–50 U/kg. Avoid rivaroxaban CrCl <15; hold 2–5 days pre-op by renal function. |
| Dabigatran | 150 mg BID (75 mg BID CrCl 15–30) | DTI; reverse with idarucizumab 5 g IV (2 × 2.5 g); dialyzable. |
| Protamine | 1 mg per 100 U UFH given in the last 2–3 h (max 50 mg, ≤5 mg/min) | Hypotension, anaphylaxis (NPH insulin, fish allergy, vasectomy), pulmonary hypertension. Excess protamine is itself anticoagulant. |
| Vitamin K (phytonadione) | Major bleed: 10 mg IV slow (over 20–30 min) · INR >10 no bleed: 2.5–5 mg PO · INR 4.5–10: hold warfarin ± 1–2.5 mg PO | Onset 6–12 h IV (24 h PO); IV anaphylactoid reactions (rare, slow infusion). Give with PCC for durable reversal. |
| 4F-PCC (Kcentra) | INR 2–3.9: 25 U/kg · 4–6: 35 U/kg · >6: 50 U/kg (max 2,500/3,500/5,000 U); fixed 1,500–2,000 U regimens used · Xa-inhibitor bleeding: 25–50 U/kg | Factors II, VII, IX, X + protein C/S + heparin. Onset 10–30 min; thrombosis risk. Contraindicated in HIT (contains heparin) and DIC. |
| Andexanet alfa | Low dose: 400 mg bolus (30 mg/min) then 4 mg/min × 2 h · High dose: 800 mg then 8 mg/min × 2 h (rivaroxaban >10 mg / apixaban >5 mg within 8 h) | Factor Xa decoy; expensive; thrombotic events; interferes with heparin (post-reversal anticoagulation). |
| Idarucizumab | 5 g IV (two 2.5 g vials within 15 min) | Dabigatran-specific monoclonal antibody fragment; can redose if rebleeding with elevated dTT. |
| Tranexamic acid | Trauma: 1 g IV over 10 min, then 1 g over 8 h (within 3 h of injury) · TBI (CRASH-3) same · Surgery: 10–15 mg/kg ± 1 mg/kg/h · Postpartum 1 g | Antifibrinolytic; seizures at high doses (cardiac surgery); avoid >3 h after trauma (harm). Renal adjust. |
| Desmopressin (DDAVP) | 0.3 mcg/kg IV over 15–30 min (hemostasis) · DI: 1–2 mcg IV/SC q8–12 h or 10–40 mcg intranasal | Releases vWF/factor VIII: uremic platelet dysfunction, vWD type 1, antiplatelet-associated ICH (controversial). Hyponatremia, tachyphylaxis. |
| Alteplase (tPA) | Massive PE: 100 mg over 2 h (or 50 mg) · Stroke: 0.9 mg/kg (max 90 mg), 10% bolus, rest over 60 min, within 4.5 h · STEMI: 15 mg bolus, 0.75 mg/kg (≤50) over 30 min, 0.5 mg/kg (≤35) over 60 min · Catheter clearance 2 mg | Hold heparin during infusion for PE; ICH 2–6%. Contraindications: recent surgery/trauma, ICH history, active bleeding. |
| Cryoprecipitate / fibrinogen concentrate | Cryo 10 units (1 pool/5–10 units raises fibrinogen ~50–100 mg/dL) · Fibrinogen concentrate 2–4 g | Target fibrinogen >150–200 mg/dL in massive hemorrhage/obstetric bleeding (per TEG/ROTEM). |
| Aspirin / P2Y₁₂ reversal | Platelets 1 apheresis unit (not for ICH on antiplatelets — PATCH showed harm); DDAVP 0.3 mcg/kg | Ticagrelor is reversible (bentracimab investigational); platelet transfusion ineffective for ticagrelor. |
| Source: CHEST Antithrombotic Guidelines; ACC Expert Consensus on Management of Bleeding in Patients on Oral Anticoagulants (2020); ASH VTE/HIT Guidelines 2018; CRASH-2 (Lancet 2010); PROPPR (JAMA 2015); EAST VTE Prophylaxis Guidelines (2022). | ||
Antiplatelets & thrombolytics
| Drug | Dose | Pearls |
|---|---|---|
| Antiplatelet agents | ||
| Aspirin | ACS: 162–325 mg chewed once, then 81 mg daily · Stroke: 160–325 mg within 24–48 h (after tPA window) · Post-CEA/stent/CABG: 81 mg daily | Irreversible COX-1 inhibitor; platelet effect lasts 7–10 days (platelet lifespan). Continue perioperatively in most vascular/cardiac patients (POISE-2: no benefit starting it, but stopping raises stent-thrombosis risk). Reye's, GI bleeding; PR route if NPO. |
| Clopidogrel | Load 300–600 mg PO, then 75 mg daily | P2Y₁₂ prodrug (CYP2C19 — poor metabolizers, omeprazole interaction). Irreversible; hold 5 days before elective surgery. TTP (rare). Weakest of the P2Y₁₂ agents. |
| Ticagrelor | Load 180 mg, then 90 mg BID (60 mg BID after 12 months) | Reversible direct P2Y₁₂ inhibitor, but hold 3–5 days pre-op (drug persists). Dyspnea (14%), bradyarrhythmias; aspirin must be ≤100 mg. Platelet transfusion does not reverse it (circulating drug inhibits new platelets); bentracimab investigational. |
| Prasugrel | Load 60 mg, then 10 mg daily (5 mg if < 60 kg or ≥ 75 y) | Irreversible; most potent; hold 7 days pre-op. Contraindicated with prior stroke/TIA; more bleeding than clopidogrel (TRITON-TIMI 38). |
| Cangrelor | 30 mcg/kg IV bolus, then 4 mcg/kg/min (PCI); bridging 0.75 mcg/kg/min | IV reversible P2Y₁₂ inhibitor; offset in ~1 h — used to bridge stented patients who must stop oral P2Y₁₂ agents for surgery (BRIDGE trial). Give oral agent at infusion end. |
| Eptifibatide / Tirofiban | Eptifibatide 180 mcg/kg bolus ×2 (10 min apart), 2 mcg/kg/min (1 mcg/kg/min CrCl < 50) · Tirofiban 25 mcg/kg bolus, 0.15 mcg/kg/min | GP IIb/IIIa inhibitors (reversible; platelet function recovers 4–8 h). PCI/ACS adjuncts, bridging. Thrombocytopenia (check platelets at 6 h); renal dosing. Abciximab (irreversible, 24–48 h) is largely unavailable. |
| Dipyridamole (+ ASA) | 200 mg ER / 25 mg ASA BID | Secondary stroke prevention alternative; headache. Not for perioperative use. |
| Antiplatelet reversal | Platelets 1 apheresis unit — not for spontaneous ICH on antiplatelets (PATCH: worse outcomes); reasonable before emergent neurosurgery per institutional protocol · DDAVP 0.3 mcg/kg IV (aspirin/clopidogrel, uremia) | Time is the only reliable reversal: aspirin 7–10 d, clopidogrel 5–7 d, prasugrel 7–10 d, ticagrelor 3–5 d. Platelet transfusion is ineffective for ticagrelor and cangrelor while drug circulates. |
| Perioperative DAPT after stent | Minimum DAPT before non-cardiac surgery: BMS 30 days; DES 6 months (3 months if surgical delay is risky; 1 month with newer DES in select cases); continue aspirin throughout when possible; resume P2Y₁₂ within 24–72 h | 2016 ACC/AHA DAPT focused update & 2024 perioperative guideline. Stent thrombosis mortality 20–45%. Bridge with cangrelor/tirofiban when interruption is unavoidable early after stenting. |
| Thrombolytics | ||
| Alteplase (tPA) | Massive PE: 100 mg IV over 2 h (50 mg over 2 h alternative; 0.6 mg/kg max 50 mg over 15 min in arrest) · Ischemic stroke: 0.9 mg/kg (max 90), 10% bolus over 1 min, remainder over 60 min, within 4.5 h · STEMI (no PCI within 120 min): 15 mg bolus, 0.75 mg/kg (≤ 50) over 30 min, 0.5 mg/kg (≤ 35) over 60 min · Catheter occlusion: 2 mg/2 mL dwell · Empyema: 10 mg intrapleural BID × 3 d with DNase 5 mg (MIST2) | Fibrin-specific serine protease; half-life 5 min. Hold heparin during PE infusion, restart when aPTT < 2× control. ICH 1–6% (higher in elderly, low weight, hypertension). Angioedema (ACE-inhibitor users). |
| Tenecteplase (TNK) | Stroke: 0.25 mg/kg IV single bolus (max 25 mg) · STEMI: weight-tiered bolus 30–50 mg (0.5 mg/kg; half dose if ≥ 75 y) · PE (off-label, PEITHO): same weight-tiered bolus | Longer half-life, more fibrin-specific, single bolus — now an accepted alteplase alternative in stroke (AcT, EXTEND-IA TNK) and preferred before thrombectomy for LVO. Same contraindications. |
| Reteplase | 10 U IV bolus ×2, 30 min apart (STEMI) | Non-weight-based double bolus; mostly historical; used in some catheter-directed protocols. |
| Catheter-directed thrombolysis | PE: alteplase 1 mg/h per catheter × 12–24 h (total 12–24 mg; ultrasound-assisted per ULTIMA/SEATTLE II) · Limb ischemia (Rutherford IIa): alteplase 0.5–1 mg/h intra-arterial with sub-therapeutic heparin (aPTT 1.2–1.5×) · DVT (iliofemoral): 0.5–1 mg/h (ATTRACT: less post-thrombotic syndrome in iliofemoral only) | Lower systemic dose; check fibrinogen q6 h (hold if < 100–150 mg/dL). Intermediate-high-risk PE: CDT vs anticoagulation alone is the subject of ongoing trials (HI-PEITHO, PEERLESS). |
| Absolute contraindications (systemic lysis) | Prior ICH; known structural cerebrovascular lesion or malignant intracranial neoplasm; ischemic stroke within 3 months (except acute stroke < 4.5 h); suspected aortic dissection; active bleeding or bleeding diathesis; significant closed-head/facial trauma within 3 months; intracranial/spinal surgery within 2 months; severe uncontrolled hypertension unresponsive to therapy | Relative: SBP > 180/110, recent major surgery (< 3 wk), internal bleeding (2–4 wk), non-compressible punctures, pregnancy, active peptic ulcer, anticoagulation, prolonged CPR (> 10 min), dementia. In arrest from confirmed massive PE, lysis is given despite CPR (continue CPR 60–90 min after). |
| Thrombolytic reversal (bleeding) | Stop infusion; cryoprecipitate 10 units (target fibrinogen > 150 mg/dL); TXA 1 g IV or aminocaproic acid 4–5 g load then 1 g/h; platelets if on antiplatelets or < 100k; FFP if INR elevated; CT head immediately if neurologic change (AHA 2019 sICH protocol) | Symptomatic ICH after stroke lysis ~2–6%; angioedema 1–5% (treat with antihistamines/steroids, icatibant/C1-esterase inhibitor, airway). |
| Source: 2016 ACC/AHA DAPT Focused Update; 2024 ACC/AHA Perioperative Cardiovascular Guideline; 2019 AHA/ASA Acute Ischemic Stroke Guideline; 2019 ESC PE Guideline & PEITHO (NEJM 2014); PATCH (Lancet 2016); BRIDGE (JAMA 2012); ATTRACT (NEJM 2017); MIST2 (NEJM 2011); Lexicomp. | ||
Antimicrobials
Empiric ICU regimens (normal renal function). De-escalate at 48–72 h on cultures; reassess duration daily. Renal dose-adjust all except: ceftriaxone, linezolid, moxifloxacin, azithromycin, doxycycline, metronidazole, clindamycin, nafcillin, and echinocandins.
| Drug | Dose | Spectrum / pearls |
|---|---|---|
| Gram-positive / MRSA | ||
| Vancomycin | Load 20–35 mg/kg IV (actual weight, max 3 g), then 15–20 mg/kg q8–12 h; target AUC₂₄/MIC 400–600 (trough 15–20 historically); 1 g q12 h if uncomplicated | MRSA, MRSE, enterococci (not VRE), C. diff (PO only). Nephrotoxicity ↑ with piperacillin-tazobactam; infusion reaction ("vancomycin flushing") — slow rate. Poor lung/CNS penetration. |
| Linezolid | 600 mg IV/PO q12 h | MRSA, VRE, toxin suppression. Thrombocytopenia (>2 wk), serotonin syndrome (SSRIs, fentanyl, meperidine), lactic acidosis, optic neuropathy. Preferred over vanc for MRSA pneumonia by some data. 100% oral bioavailability. |
| Daptomycin | 6–10 mg/kg IV q24 h (8–12 for bacteremia/endocarditis); q48 h if CrCl <30 | MRSA, VRE bacteremia/endocarditis, skin. Inactivated by surfactant — never for pneumonia. CK weekly (myopathy); eosinophilic pneumonia. |
| Ceftaroline | 600 mg IV q12 h (q8 h for bacteremia) | 5th-gen cephalosporin: MRSA + typical gram-negatives (no Pseudomonas). MRSA pneumonia alternative. |
| Nafcillin / Oxacillin | 2 g IV q4 h | Drug of choice for MSSA bacteremia/endocarditis (or cefazolin 2 g q8 h — better tolerated). Interstitial nephritis, neutropenia. |
| Clindamycin | 600–900 mg IV q8 h | Toxin suppression in necrotizing fasciitis/TSS (add to β-lactam); anaerobes above the diaphragm, MSSA/CA-MRSA (check D-test). C. diff risk. |
| Ampicillin | 2 g IV q4–6 h | Enterococcus faecalis (with gentamicin or ceftriaxone for endocarditis), Listeria (meningitis >50 y). |
| Broad-spectrum β-lactams (anti-pseudomonal) | ||
| Piperacillin-tazobactam | 4.5 g IV q6 h (or 4.5 g q8 h as 4-h extended infusion); load 4.5 g over 30 min first | Gram-negative incl. Pseudomonas, anaerobes, enterococci (faecalis), MSSA. Intra-abdominal sepsis, HAP/VAP, NSTI. AKI with vancomycin; sodium load; seizures in renal failure. |
| Cefepime | 2 g IV q8 h (1–2 g q12 h if CrCl 30–60; 1 g q24 h <30); 2 g q8 h extended infusion for Pseudomonas | 4th-gen: Pseudomonas, Enterobacterales (incl. AmpC — but not ESBL); no anaerobes. Neurotoxicity (encephalopathy, myoclonus, NCSE) with renal impairment — a favorite exam pitfall. |
| Ceftazidime | 2 g IV q8 h | Pseudomonas; weak gram-positive activity. Ceftazidime-avibactam 2.5 g q8 h for CRE (KPC/OXA-48), MDR Pseudomonas. |
| Meropenem | 1 g IV q8 h (2 g q8 h meningitis/CF/extended infusion over 3 h); 500 mg q8 h with CrCl 26–50 | ESBL, AmpC producers, Pseudomonas, anaerobes; not MRSA, VRE, Stenotrophomonas. Seizure risk lower than imipenem; ↓ valproate levels dramatically. |
| Imipenem-cilastatin | 500 mg–1 g IV q6 h | Broadest; seizures (renal failure, CNS lesions). Ertapenem 1 g daily: no Pseudomonas/Acinetobacter/enterococcus — good for ESBL outpatient/step-down. |
| Aztreonam | 2 g IV q8 h | Gram-negatives incl. Pseudomonas only; safe in severe penicillin allergy (except ceftazidime cross-reactivity via shared side chain). |
| Other gram-negative coverage | ||
| Ceftriaxone | 1–2 g IV q24 h (2 g q12 h meningitis) | CAP, pyelonephritis, SBP (1 g), variceal bleed prophylaxis, meningitis (+ vanc ± ampicillin). No Pseudomonas/enterococcus. Biliary sludge; avoid with calcium in neonates. |
| Gentamicin / Tobramycin | Once-daily 5–7 mg/kg (adjusted body weight if obese); traditional 1.7–2 mg/kg q8 h; synergy 1 mg/kg q8 h (endocarditis) | Concentration-dependent killing; nephro-/ototoxicity; neuromuscular blockade. Amikacin 15–20 mg/kg daily. Poor lung penetration; not for monotherapy of Pseudomonas pneumonia. |
| Ciprofloxacin / Levofloxacin | Cipro 400 mg IV q8–12 h (750 PO BID) · Levo 750 mg IV/PO q24 h | Pseudomonas (cipro > levo), atypicals (levo/moxi). QT prolongation, tendinopathy, aortic aneurysm/dissection warning, C. diff, delirium; dysglycemia. Rising resistance — avoid empiric use where possible. |
| Azithromycin | 500 mg IV/PO q24 h (× 3–5 days) | Atypical CAP coverage with ceftriaxone; immunomodulatory. QT prolongation. |
| Doxycycline | 100 mg IV/PO q12 h | CA-MRSA skin, atypicals, rickettsia, Vibrio (with ceftriaxone), leptospirosis. No renal adjustment. |
| TMP-SMX | 8–10 mg/kg/day (TMP) IV divided q6–8 h; PJP 15–20 mg/kg/day | Stenotrophomonas drug of choice, CA-MRSA, PJP (+ prednisone if PaO₂ <70), Nocardia. Hyperkalemia, ↑ creatinine (tubular secretion), marrow suppression. |
| Polymyxin B / Colistin | Polymyxin B 2.5 mg/kg load, then 1.25–1.5 mg/kg q12 h · Colistin (CMS) 300 mg CBA load, then 150–180 mg q12 h (renal adjust) | Last-line for carbapenem-resistant Acinetobacter/Pseudomonas/CRE; nephro-/neurotoxic. Newer agents preferred when active: ceftazidime-avibactam, meropenem-vaborbactam, cefiderocol. |
| Anaerobes, C. difficile, fungi, viruses | ||
| Metronidazole | 500 mg IV/PO q8 h (or 1 g q12 h); fulminant C. diff 500 mg IV q8 h with PO vancomycin | Anaerobes below the diaphragm, amebiasis, giardiasis. Disulfiram reaction, peripheral neuropathy (prolonged), ↑ INR with warfarin. Not for aspiration pneumonia monotherapy. |
| Vancomycin (oral) | 125 mg PO q6 h × 10 d · Fulminant: 500 mg PO/NG q6 h + IV metronidazole 500 mg q8 h ± 500 mg in 100 mL rectal q6 h if ileus | C. difficile first-line (or fidaxomicin 200 mg BID). Not absorbed. Surgery (subtotal colectomy or diverting loop ileostomy + lavage) for toxic megacolon, perforation, refractory shock, lactate >5. |
| Fluconazole | 800 mg (12 mg/kg) IV/PO load, then 400 mg (6 mg/kg) daily | C. albicans, cryptococcus consolidation, Candida UTI (only azole with urinary levels). Poor against C. glabrata/krusei/auris. QT, hepatotoxicity, CYP interactions (tacrolimus, warfarin). |
| Micafungin / Caspofungin | Micafungin 100 mg IV daily · Caspofungin 70 mg load, then 50 mg daily | Echinocandins: first-line for candidemia and invasive candidiasis in ICU (IDSA); no renal adjustment. Poor CNS/eye/urine penetration. |
| Amphotericin B (liposomal) | 3–5 mg/kg IV daily (5–10 for mucormycosis) | Mucormycosis (plus surgical debridement), cryptococcal meningitis (+ flucytosine), refractory candidiasis. Nephrotoxicity, K⁺/Mg²⁺ wasting, infusion reactions; saline-load. |
| Voriconazole | 6 mg/kg IV q12 h × 2, then 4 mg/kg q12 h (PO 200–300 mg BID); trough 1–5.5 mcg/mL | Invasive aspergillosis first-line. Visual disturbance, hepatotoxicity, QT, photosensitivity; IV vehicle (cyclodextrin) accumulates CrCl <50. Many CYP interactions. |
| Acyclovir | 10 mg/kg IV q8 h (HSV encephalitis, 14–21 d); 5 mg/kg q8 h mucocutaneous | Crystal nephropathy — hydrate, ideal body weight, renal adjust. Start empirically for encephalitis before PCR. |
| Oseltamivir | 75 mg PO BID × 5 d (longer in critical illness/immunocompromised) | Start regardless of symptom duration in hospitalized influenza. Renal adjust CrCl <60. |
| Ganciclovir | 5 mg/kg IV q12 h induction (14–21 d), then 5 mg/kg daily | CMV disease in transplant/immunocompromised; marrow suppression (neutropenia), nephrotoxicity; foscarnet if resistant. |
| Common empiric regimens | ||
| Septic shock, unknown source | Vancomycin + piperacillin-tazobactam (or cefepime/meropenem) within 1 h; add antifungal if high risk (TPN, prior broad abx, perforation, colonization) | Every hour of delay increases mortality. Cultures before antibiotics if no delay. Source control within 6–12 h. |
| HAP / VAP | Piperacillin-tazobactam or cefepime or meropenem ± vancomycin/linezolid (MRSA risk: prior IV abx within 90 d, unit MRSA prevalence >10–20%) ± second anti-pseudomonal if septic shock/high resistance; 7 days | IDSA/ATS 2016. Use local antibiogram. Procalcitonin to guide stopping. |
| Complicated intra-abdominal infection | Community: ceftriaxone + metronidazole or piperacillin-tazobactam · Healthcare-associated/severe: piperacillin-tazobactam or meropenem ± vancomycin ± echinocandin; 4 days after source control (STOP-IT) | Enterococcal coverage for healthcare-associated, immunocompromised, valvular disease, or post-op recurrent infection. |
| Necrotizing soft tissue infection | Vancomycin + piperacillin-tazobactam (or carbapenem) + clindamycin 900 mg q8 h; penicillin G 4 million U q4 h + clindamycin for group A strep | Immediate surgical debridement is definitive; re-look in 24 h. Clindamycin suppresses toxin (Eagle effect). |
| Bacterial meningitis (adult) | Ceftriaxone 2 g q12 h + vancomycin (± ampicillin 2 g q4 h if >50 y/immunocompromised) + dexamethasone 0.15 mg/kg q6 h × 4 d (before/with first dose); post-neurosurgical: vancomycin + cefepime/meropenem | Don't delay antibiotics for LP/CT. Dexamethasone benefits pneumococcal meningitis. |
| Aspiration pneumonia | Ampicillin-sulbactam 3 g q6 h, or ceftriaxone ± metronidazole; piperacillin-tazobactam if HAP risk | Aspiration pneumonitis (chemical) needs no antibiotics; reassess at 48 h. |
| Open fracture prophylaxis | Cefazolin 2 g IV q8 h (3 g if >120 kg) for Gustilo I–II (24 h); add gram-negative coverage (e.g., ceftriaxone or piperacillin-tazobactam) for type III; penicillin for farm/soil contamination | Give within 1 h of injury (EAST). Continue 72 h or 24 h after wound closure for type III. |
| Source: Surviving Sepsis Campaign 2021; IDSA/ATS HAP/VAP Guidelines 2016; IDSA Candidiasis 2016 & Aspergillosis 2016; IDSA/SHEA C. difficile 2021 update; SIS/IDSA Intra-abdominal Infection 2017 & STOP-IT (NEJM 2015); IDSA Skin and Soft Tissue 2014; Sanford Guide 2025; ASHP/IDSA Vancomycin Consensus 2020; EAST Open Fracture Guideline 2011. | ||
Electrolytes, endocrine & metabolic
| Drug | Dose | Pearls |
|---|---|---|
| Insulin (regular) infusion | ICU hyperglycemia: start when glucose >180; target 140–180 mg/dL · DKA/HHS: 0.1 U/kg/h (± 0.1 U/kg bolus) after K⁺ >3.3; add D5 when glucose <250 (DKA) / <300 (HHS) | NICE-SUGAR: tight control (81–108) ↑ mortality. Hypokalemia, hypophosphatemia. Hyperkalemia: 10 U IV + 25–50 g dextrose (monitor glucose 4–6 h). |
| Hydrocortisone | Septic shock: 200 mg/day (50 mg q6 h or continuous) · Adrenal crisis: 100 mg IV then 50 q6 h / 200 mg/day · Stress dosing for chronic steroid users: 50–100 mg q8 h | Surviving Sepsis: for ongoing vasopressor need (NE ≥0.25 mcg/kg/min ≥4 h). Fludrocortisone 50 mcg optional (APROCCHSS). Taper over days when shock resolves. Hyperglycemia, myopathy, hypernatremia. |
| Dexamethasone | Meningitis 0.15 mg/kg q6 h × 4 d · Cerebral edema (tumor) 10 mg IV then 4 mg q6 h · COVID/ARDS 6 mg daily × 10 d · PONV 4–8 mg | No mineralocorticoid effect — inappropriate for adrenal crisis alone. Do not use in TBI (CRASH: ↑ mortality). |
| Methylprednisolone | ARDS (early, moderate–severe): 1 mg/kg/day taper (Meduri) · Spinal cord injury: not recommended · Pulse: 1 g daily × 3 | Corticosteroids in ARDS: DEXA-ARDS supports dexamethasone 20 mg × 5 d, 10 mg × 5 d. Avoid starting >14 d after ARDS onset. |
| Levothyroxine | Myxedema coma: 200–400 mcg IV load (lower in elderly/CAD), then 50–100 mcg IV daily (1.6 mcg/kg PO ≈ 75% IV); ± liothyronine 5–20 mcg then 2.5–10 mcg q8 h | Give hydrocortisone first. Passive rewarming; avoid over-aggressive warming (vasodilation). |
| Propylthiouracil / Methimazole | Thyroid storm: PTU 500–1,000 mg load, then 250 mg q4 h (or methimazole 20 mg q4–6 h); iodine (SSKI 5 drops q6 h or Lugol's 10 drops q8 h) ≥1 h later; propranolol 60–80 mg q4–6 h or esmolol; hydrocortisone 100 mg q8 h | PTU blocks T4→T3 conversion (preferred in storm, 1st trimester); hepatotoxicity. Methimazole for maintenance. |
| Potassium chloride | IV 10 mEq/h peripheral, 20 mEq/h central (up to 40 with monitoring); 10 mEq raises K⁺ ~0.1 mEq/L; PO 40 mEq doses | Correct Mg²⁺ first (refractory hypokalemia). Target K⁺ ≥4 in cardiac patients. Use KPhos if hypophosphatemic. |
| Magnesium sulfate | 1–2 g IV over 1 h (mild); 4 g over 4 h (severe/symptomatic; 2 g push in torsades); eclampsia 4–6 g load then 1–2 g/h | Renal excretion — half dose in AKI. Target >2 mg/dL in arrhythmias/hypokalemia. Toxicity: loss of reflexes → give calcium. |
| Calcium | Gluconate 1–2 g IV over 10 min (3 g for hyperkalemia with ECG changes; 1 g = 93 mg elemental) · Chloride 1 g IV central (272 mg elemental, 3×) · Massive transfusion: 1 g CaCl per 2–4 units | Correct for albumin or check ionized Ca (<1.1 mmol/L treat if symptomatic/bleeding/on pressors). Calcium chloride peripheral extravasation → necrosis. Do not mix with bicarbonate/phosphate. |
| Phosphate (Na or K phos) | Serum PO₄ 2–2.5: 0.16 mmol/kg; 1–2: 0.32 mmol/kg; <1: 0.64 mmol/kg IV over 4–6 h (max ~30–45 mmol/dose); PO 250–500 mg (8–16 mmol) TID | Use ideal body weight in obesity. KPhos delivers 4.4 mEq K⁺/3 mmol PO₄ (limit K⁺ rate). Hypophosphatemia: refeeding, DKA, respiratory failure to wean, CRRT. |
| Sodium bicarbonate | 50–100 mEq (1–2 amps of 8.4%) IV; infusion 150 mEq in 1 L D5W · BICAR-ICU: target pH ≥7.30 in pH ≤7.20 with AKI · Hyperkalemia 50 mEq · TCA overdose 1–2 mEq/kg bolus, target pH 7.50–7.55 | Each amp 50 mEq Na⁺/1,000 mOsm. Generates CO₂ — ventilate; hypocalcemia, hypernatremia. Not for DKA pH >6.9 or routine lactic acidosis. |
| Hypertonic saline (3%) | Symptomatic hyponatremia: 100–150 mL bolus over 10–20 min, repeat ×2 (goal ↑4–6 mEq/L; ≤8 per 24 h) · ICP: 250 mL 3% or 30 mL 23.4% (central) over 10–20 min; infusion 3% 0.5–1 mL/kg/h to Na 145–155 | Peripheral 3% acceptable short-term. Monitor Na q2–4 h; osm <320, Na <160. Overcorrection → D5W + DDAVP 2 mcg. |
| Mannitol | 0.25–1 g/kg IV over 15–20 min; repeat q4–6 h; hold if osm >320 or osm gap >20 | Osmotic diuretic — causes hypovolemia/hypotension (avoid in shock); rebound; AKI. Hypertonic saline preferred in hypovolemic/hyponatremic patients. Needs intact BBB and filter. |
| Hyperkalemia bundle | Calcium (above) → insulin 10 U + D50 25–50 g → albuterol 10–20 mg neb → NaHCO₃ if acidotic → furosemide 40–80 mg IV → patiromer 8.4 g / SZC 10 g TID → dialysis | Membrane stabilization (minutes) → shift (15–30 min, 1 mEq/L) → removal. Recheck K⁺ q1–2 h. Sodium polystyrene is slow and associated with colonic necrosis. |
| Thiamine | Wernicke: 500 mg IV TID × 2–3 d, then 250 mg daily · Prophylaxis/refeeding/alcohol: 100–200 mg IV daily · Septic shock (adjunct): 200 mg q12 h | Give before or with dextrose. Also for beriberi-associated lactic acidosis with TPN/malnutrition. |
| Vasopressin (DI) / Desmopressin | DDAVP 1–2 mcg IV/SC q8–12 h (titrate to UOP <200–300 mL/h); vasopressin 0.5–2.5 U/h infusion in brain-dead donors | Central DI after TBI/pituitary surgery/brain death: UOP >300 mL/h × 2 h, Na ↑, urine osm <300. Replace free water deficit. |
| Source: NICE-SUGAR (NEJM 2009); Surviving Sepsis Campaign 2021; ADRENAL & APROCCHSS (NEJM 2018); ADA Hyperglycemic Crises 2024; Verbalis et al. Hyponatremia Guidelines (Am J Med 2013); BICAR-ICU (Lancet 2018); ATA Thyroid Guidelines 2016; KDIGO; Lexicomp. | ||
Neurocritical care
| Drug | Dose | Pearls |
|---|---|---|
| Lorazepam / Midazolam (status epilepticus) | Lorazepam 0.1 mg/kg IV (max 4 mg/dose, repeat once) · Midazolam 10 mg IM (>40 kg) or 0.2 mg/kg · Diazepam 0.15–0.2 mg/kg IV (max 10 mg) or 20 mg PR | First-line at 5 min of seizure. Under-dosing is the commonest error (RAMPART, ESETT). |
| Levetiracetam | 60 mg/kg IV (max 4,500 mg) over 10 min (status) · 1,000–1,500 mg BID maintenance · TBI prophylaxis 500–1,000 mg BID × 7 d | Second-line, equivalent to fosphenytoin/valproate (ESETT). Renal adjust; behavioral side effects. Preferred over phenytoin for post-traumatic seizure prophylaxis (no monitoring). |
| Fosphenytoin / Phenytoin | Fosphenytoin 20 mg PE/kg IV at ≤150 mg PE/min · Phenytoin 20 mg/kg at ≤50 mg/min · maintenance 100 mg q8 h; free level 1–2 mcg/mL | Hypotension/arrhythmia with rapid infusion (phenytoin's propylene glycol; "purple glove"). Correct level for albumin. Many interactions; not for toxic seizures (theophylline, TCAs). |
| Valproate | 20–40 mg/kg IV (max 3,000 mg) at 10 mg/kg/min; maintenance 250–500 mg q8 h | Hepatotoxicity, pancreatitis, thrombocytopenia, hyperammonemia; meropenem drops levels precipitously. |
| Propofol / midazolam / ketamine (refractory SE) | Propofol 1–2 mg/kg then 30–200 mcg/kg/min · Midazolam 0.2 mg/kg then 0.05–2 mg/kg/h · Ketamine 1–3 mg/kg then 1–10 mg/kg/h | Third-line with continuous EEG; target burst suppression or seizure cessation for 24–48 h. Pentobarbital 5–15 mg/kg then 0.5–5 mg/kg/h as alternative. |
| Nimodipine | 60 mg PO/NG q4 h × 21 days (30 mg q2 h if hypotensive) | Improves outcome after aneurysmal SAH (reduces delayed cerebral ischemia). Never IV in the U.S. (fatal hypotension when given IV by error). |
| Hypertonic saline / Mannitol | See electrolytes table | Treat ICP >22 mmHg; CPP 60–70 (BTF 4th ed.). Tier: HOB 30°, sedation, osmotherapy, CSF drainage, brief hyperventilation (PaCO₂ 30–35), then barbiturates/hypothermia/decompressive craniectomy (RESCUEicp: ↓ mortality, ↑ severe disability). |
| Nicardipine / Clevidipine (ICH) | Target SBP 140 mmHg (avoid <130) within 1 h for ICH (INTERACT-2/ATACH-2); ischemic stroke <185/110 pre-tPA, <180/105 after; permissive to 220/120 if no tPA | Reverse anticoagulants (PCC, idarucizumab, andexanet). Platelets contraindicated for antiplatelet-associated ICH (PATCH). |
| Aspirin / Antiplatelets (stroke) | Aspirin 325 mg within 24–48 h of ischemic stroke (after tPA window); DAPT 21 days for minor stroke/TIA (POINT/CHANCE) | Also aspirin after CEA/CAS; ticagrelor alternative. |
| Alteplase / Tenecteplase (stroke) | Alteplase 0.9 mg/kg (max 90) within 4.5 h · Tenecteplase 0.25 mg/kg (max 25 mg) single bolus — now accepted alternative | Thrombectomy for LVO up to 24 h (DAWN/DEFUSE-3) regardless of lytics. |
| Phenobarbital (withdrawal) | 10 mg/kg IV load (ideal body weight) over 30 min, or 130–260 mg IV q15–30 min; then 65–130 mg q8 h taper | Alternative or adjunct to benzodiazepines for severe alcohol withdrawal; long half-life (~4 days) — self-tapering. Respiratory depression with benzodiazepines. |
| Dexmedetomidine / Clonidine (withdrawal adjuncts) | Dexmedetomidine 0.2–1.5 mcg/kg/h · Clonidine 0.1–0.3 mg PO q6–8 h | Adjuncts only — do not prevent withdrawal seizures or DTs. Benzodiazepines/phenobarbital remain the backbone. |
| Source: Brain Trauma Foundation Guidelines 4th ed. (2016); AHA/ASA ICH 2022 & Acute Ischemic Stroke 2019 Guidelines; AHA/ASA aSAH 2023; Neurocritical Care Society Status Epilepticus Guideline 2012 & ESETT (NEJM 2019); ASAM Alcohol Withdrawal Guideline 2020. | ||
GI, hepatic & renal
| Drug | Dose | Pearls |
|---|---|---|
| Pantoprazole | SUP: 40 mg IV/PO daily · Upper GI bleed: 80 mg IV bolus then 8 mg/h × 72 h, or 40 mg IV q12 h (equivalent) | SUP indications: MV >48 h, coagulopathy, shock, liver disease, prior GI bleed. Stop when risk resolves. Associated with C. diff and pneumonia (small); SUP-ICU: no mortality difference. |
| Famotidine | 20 mg IV/PO q12 h (renal adjust) | H2 blocker alternative for SUP; thrombocytopenia (rare), delirium in elderly/renal failure. |
| Sucralfate | 1 g PO/NG q6 h | Coats mucosa; binds other drugs (separate by 2 h); aluminum accumulation in renal failure. |
| Octreotide | Variceal bleed: 50 mcg IV bolus, then 50 mcg/h × 2–5 d · High-output fistula/chyle leak: 100–200 mcg SC q8 h | Splanchnic vasoconstriction. Hyperglycemia, bradycardia, gallstones. Terlipressin alternative (also HRS). |
| Erythromycin / Metoclopramide | Erythromycin 250 mg IV q6 h (or 3 mg/kg) × ≤3–5 d · Metoclopramide 10 mg IV q6 h (renal adjust) | Prokinetics for feeding intolerance/gastroparesis; erythromycin before EGD for bleeding (250 mg IV 30–60 min prior). Tachyphylaxis; QT prolongation; metoclopramide EPS/tardive dyskinesia. |
| Lactulose | 20–30 g (30–45 mL) PO/NG q1–2 h until stool, then TID–QID titrated to 2–3 soft stools/day; enema 300 mL in 700 mL water | Hepatic encephalopathy first-line; add rifaximin 550 mg BID for secondary prevention. Avoid over-diarrhea (hypernatremia, volume depletion). |
| Albumin | SBP: 1.5 g/kg on day 1, 1 g/kg on day 3 · Large-volume paracentesis (>5 L): 6–8 g per L removed · HRS: 1 g/kg (max 100 g) then 20–40 g/day with terlipressin/vasoconstrictors | No benefit over crystalloid for sepsis resuscitation (ALBIOS, SAFE); harmful in TBI (SAFE-TBI). |
| Terlipressin | HRS-AKI: 1 mg IV q6 h (0.85 mg), titrate to 2 mg q6 h with albumin (CONFIRM) | FDA-approved 2022; respiratory failure risk — avoid with volume overload or SpO₂ <90%. Alternative: norepinephrine or midodrine 7.5–15 mg TID + octreotide. |
| N-acetylcysteine | Acetaminophen: 150 mg/kg IV over 1 h, 50 mg/kg over 4 h, 100 mg/kg over 16 h (21-h protocol); continue if LFTs rising · Non-APAP ALF: same regimen (benefit in early-grade encephalopathy) | Most effective within 8 h; anaphylactoid reactions (slow first bag). PO 140 mg/kg then 70 mg/kg q4 h × 17 doses. |
| Furosemide | 20–80 mg IV bolus (2–2.5× home oral dose; up to 200 mg if AKI/diuretic-resistant); infusion 5–20 mg/h (after loading bolus) | Loop diuretic (1 mg IV ≈ 2 mg PO). Bolus vs infusion equivalent (DOSE). Ototoxicity with rapid high doses; hypokalemia/hypomagnesemia; contraction alkalosis. Sulfa allergy — use ethacrynic acid. |
| Bumetanide / Torsemide | Bumetanide 0.5–2 mg IV (1 mg ≈ 40 mg furosemide); infusion 0.5–2 mg/h · Torsemide 10–40 mg IV/PO (20 mg ≈ 40 mg furosemide) | Better oral bioavailability than furosemide (torsemide ~80–100%). |
| Chlorothiazide / Metolazone | Chlorothiazide 250–500 mg IV q12 h · Metolazone 5–10 mg PO 30 min before loop | Sequential nephron blockade for loop-diuretic resistance; profound hypokalemia/hyponatremia — monitor closely. |
| Acetazolamide | 250–500 mg IV/PO q8–12 h × 1–3 days | Post-diuretic metabolic (contraction) alkalosis; carbonic anhydrase inhibitor. Hypokalemia; avoid in cirrhosis (ammonia), sulfa allergy. |
| CRRT anticoagulation | Regional citrate (ACD-A ~150–180 mL/h prefilter; target post-filter iCa 0.25–0.35 mmol/L, systemic iCa 1.1–1.3) or heparin 5–10 U/kg/h (aPTT 35–45 s) | Citrate preferred (KDIGO) unless liver failure/shock with lactate >8 (citrate accumulation: total/ionized Ca ratio >2.5). Dose 20–25 mL/kg/h effluent. |
| Source: ACG Upper GI Bleeding 2021; AASLD Portal Hypertensive Bleeding 2017, HRS & ALF guidances; SUP-ICU (NEJM 2018); DOSE (NEJM 2011); KDIGO AKI 2012; STARRT-AKI (NEJM 2020); ASPEN/SCCM Nutrition Guidelines 2016/2022. | ||
Toxicology & antidotes
| Toxin / situation | Antidote & dose | Pearls |
|---|---|---|
| Opioids | Naloxone 0.04–0.4 mg IV titrated (2 mg if apneic; up to 10 mg); infusion ⅔ effective dose/h | Goal: ventilation, not full alertness. Long-acting opioids (methadone) need infusion/observation ≥6–12 h. |
| Benzodiazepines | Flumazenil 0.2 mg IV q1 min to 1 mg (3 mg max) | Rarely indicated; seizures in dependence/TCA co-ingestion. Support airway instead. |
| Acetaminophen | NAC 21-h IV protocol (see GI table); activated charcoal 1 g/kg within 1–2 h | Rumack-Matthew nomogram from 4 h; treat if >150 mcg/mL at 4 h; chronic/unknown-time ingestions — treat if any level detectable with elevated AST. |
| Salicylates | NaHCO₃ 1–2 mEq/kg bolus, then 150 mEq/L D5W at 2–3× maintenance (urine pH 7.5–8, serum pH ≤7.55); K⁺ repletion; hemodialysis if level >90–100 mg/dL, altered mental status, pulmonary edema, renal failure, or clinical deterioration | Avoid intubation if possible (hyperventilation is compensatory); if intubated, match minute ventilation. Glucose to the brain — give dextrose if any neuro symptoms. |
| Tricyclic antidepressants | NaHCO₃ 1–2 mEq/kg boluses for QRS >100 ms, arrhythmia, or hypotension; target pH 7.50–7.55; lipid emulsion for refractory | Sodium channel blockade. Avoid class IA/IC/III antiarrhythmics and physostigmine. Norepinephrine for hypotension. |
| β-blockers | Glucagon 3–10 mg IV bolus, then 3–5 mg/h; high-dose insulin 1 U/kg bolus then 1–10 U/kg/h with D10–D50 infusion; calcium; catecholamines; lipid emulsion; pacing/ECMO | Glucagon causes vomiting — protect airway. Propranolol: sodium-channel effects → bicarbonate; sotalol → torsades. |
| Calcium-channel blockers | Calcium chloride 1–2 g (or gluconate 3–6 g) IV, repeat; high-dose insulin as above (first-line); norepinephrine/epinephrine; methylene blue or lipid emulsion for refractory vasoplegia; ECMO | Hyperglycemia with normal mental status suggests CCB (vs β-blocker: hypoglycemia). Whole-bowel irrigation for extended-release. |
| Digoxin | Digoxin immune Fab: acute known dose — vials = mg ingested × 0.8 / 0.5; steady-state — vials = level (ng/mL) × kg / 100; empiric 10 vials acute, 3–6 chronic | Indications: life-threatening arrhythmia, K⁺ >5 (acute), level >10–15. Avoid calcium (controversial) and cardioversion (use lowest energy). Treat hyperkalemia after Fab. |
| Local anesthetics (LAST) | 20% lipid emulsion 1.5 mL/kg bolus (100 mL if >70 kg), then 0.25 mL/kg/min; repeat bolus ×2; max ~12 mL/kg | Benzodiazepines for seizures; reduce epinephrine to ≤1 mcg/kg; avoid lidocaine, procainamide, vasopressin, CCBs, β-blockers. Prolonged CPR/ECMO. |
| Cyanide | Hydroxocobalamin 5 g IV over 15 min (repeat once) ± sodium thiosulfate 12.5 g IV | Smoke inhalation + lactate >8–10 + coma. Avoid nitrites if concurrent CO poisoning. Red urine/skin, interferes with colorimetric labs and dialysis sensors. |
| Carbon monoxide | 100% O₂ via non-rebreather/ETT; hyperbaric O₂ (2.5–3 ATA) for COHb >25%, LOC, neuro deficit, pregnancy with COHb >15–20%, myocardial ischemia | Pulse oximetry falsely normal; use co-oximetry. Half-life: 4–5 h room air, ~60–90 min on 100% O₂, ~20–30 min HBO. |
| Methemoglobinemia | Methylene blue 1–2 mg/kg IV over 5 min; repeat in 1 h if MetHb >30% or symptomatic | Causes: dapsone, benzocaine/lidocaine, nitrates, nitric oxide. SpO₂ ~85% regardless; chocolate-brown blood. Ineffective/harmful in G6PD deficiency — exchange transfusion. Serotonin syndrome with serotonergic drugs. |
| Toxic alcohols (methanol, ethylene glycol) | Fomepizole 15 mg/kg IV load, then 10 mg/kg q12 h × 4, then 15 mg/kg q12 h (q4 h during dialysis); hemodialysis for pH <7.25, level >50 mg/dL, end-organ injury; folate (methanol) or thiamine/pyridoxine (EG) | Anion gap + osmolar gap (>10). Ethanol infusion if fomepizole unavailable (target 100–150 mg/dL). |
| Organophosphates / nerve agents | Atropine 2–5 mg IV, doubling q3–5 min until secretions dry (not pupils); infusion 10–20% of loading dose/h · Pralidoxime 1–2 g IV over 15–30 min, then 500 mg/h · Benzodiazepines for seizures | SLUDGE/DUMBELS; bradycardia, bronchorrhea is the killer. Decontaminate — protect staff. Avoid succinylcholine (prolonged block). |
| Sulfonylureas | Dextrose then octreotide 50–100 mcg SC q6–8 h × 24 h | Octreotide suppresses insulin release; observe 24 h after last dose. Avoid prophylactic dextrose infusions alone (stimulate more insulin). |
| Iron | Deferoxamine 15 mg/kg/h IV (up to 35 mg/kg/h; max 6–8 g/day) for level >500 mcg/dL or shock/acidosis | Whole-bowel irrigation for radiopaque pills; "vin rosé" urine confirms chelation. Hypotension with rapid infusion; ARDS with prolonged use >24 h. |
| Serotonin syndrome | Stop agents; benzodiazepines; cyproheptadine 12 mg PO then 2 mg q2 h (max 32 mg/day); cooling; paralysis/intubation if T >41 °C | Hyperreflexia/clonus (lower > upper), mydriasis, diarrhea; onset <24 h. Linezolid, fentanyl, methylene blue, ondansetron, tramadol are common ICU culprits. |
| Neuroleptic malignant syndrome | Stop antipsychotic/restart dopamine agonist; bromocriptine 2.5–5 mg PO q8 h; dantrolene 1–2.5 mg/kg IV; benzodiazepines; cooling | "Lead-pipe" rigidity, hyporeflexia, bradykinesia; onset days–weeks; CK markedly elevated. Metoclopramide/haloperidol/abrupt levodopa withdrawal. |
| Anaphylaxis | Epinephrine 0.3–0.5 mg IM (anterolateral thigh) q5–15 min; refractory: 1–10 mcg/min IV infusion; crystalloid 1–2 L; H1/H2 blockers and steroids are adjuncts only; glucagon 1–5 mg IV if β-blocked | Delay in epinephrine is the main cause of death. Observe 4–24 h for biphasic reaction. Sugammadex, rocuronium, cefazolin, chlorhexidine common perioperative triggers. |
| Hyperthermia (heat stroke / MH / NMS) | Evaporative/immersion cooling to <39 °C within 30 min; dantrolene only for MH (2.5 mg/kg); benzodiazepines for shivering/agitation; avoid antipyretics | Antipyretics don't work for non-pyrogenic hyperthermia. Watch for rhabdomyolysis, DIC, liver injury. |
| Source: Goldfrank's Toxicologic Emergencies, 11th ed.; ACMT/AACT position statements; ASRA LAST Checklist 2020; AHA ACLS 2020 special circumstances; EXTRIP recommendations; Lexicomp. | ||
Adult dosing for study purposes only. Confirm against institutional protocols, pharmacy, and current package inserts.
Score: 0 / 0
Questions are original study items written to match the ABS Surgical Critical Care exam's format (clinical vignettes, single best answer, calculations, management judgment); they are not actual exam content, which is confidential. Explanations cite the trial or guideline they draw on.
Sources & references
Dosing tables and question explanations are drawn from the following guidelines, landmark trials, and references (most recent editions as of 2026).
Guidelines
- Evans L, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021;49:e1063.
- Devlin JW, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS). Crit Care Med 2018;46:e825.
- Murray MJ, et al. Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient. Crit Care Med 2016;44:2079.
- Kalil AC, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 IDSA/ATS Guidelines. Clin Infect Dis 2016;63:e61.
- Pappas PG, et al. IDSA Clinical Practice Guideline for the Management of Candidiasis: 2016 Update. Clin Infect Dis 2016;62:e1.
- Johnson S, et al. IDSA/SHEA Clinical Practice Guideline: 2021 Focused Update on Management of Clostridioides difficile Infection in Adults. Clin Infect Dis 2021;73:e1029.
- Mazuski JE, et al. Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect 2017;18:1.
- Rybak MJ, et al. Therapeutic Monitoring of Vancomycin: ASHP/IDSA/PIDS/SIDP Consensus Guideline 2020. Am J Health-Syst Pharm 2020;77:835.
- Panchal AR, et al. 2020 AHA Guidelines for CPR and Emergency Cardiovascular Care — Adult Basic and Advanced Life Support. Circulation 2020;142:S366.
- Carney N, et al. Guidelines for the Management of Severe Traumatic Brain Injury, 4th ed. Brain Trauma Foundation, Neurosurgery 2017;80:6.
- Greenberg SM, et al. 2022 AHA/ASA Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage. Stroke 2022;53:e282.
- Hoh BL, et al. 2023 AHA/ASA Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage. Stroke 2023;54:e314.
- Brophy GM, et al. Guidelines for the Evaluation and Management of Status Epilepticus. Neurocrit Care 2012;17:3.
- Tomaselli GF, et al. 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants. J Am Coll Cardiol 2020;76:594.
- Cuker A, et al. American Society of Hematology 2018 Guidelines for Management of VTE: Heparin-Induced Thrombocytopenia. Blood Adv 2018;2:3360.
- Yorkgitis BK, et al. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma Clinical Protocol for VTE Prophylaxis in Trauma. J Trauma Acute Care Surg 2022;92:597.
- McClave SA, et al. ASPEN/SCCM Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient (2016) and Compher C, et al. 2022 update. JPEN 2022;46:12.
- KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012;2:1.
- Verbalis JG, et al. Diagnosis, Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations. Am J Med 2013;126:S1.
- American Burn Association. Advanced Burn Life Support Course Provider Manual, 2018 update (consensus formula 2 mL/kg/%TBSA).
- American College of Surgeons Committee on Trauma. ATLS: Advanced Trauma Life Support, 10th ed., 2018.
- American College of Surgeons. Statement on Advance Directives by Patients: "Do Not Resuscitate" in the Operating Room (required reconsideration), 2014.
- Neal JM, et al. ASRA Practice Advisory on Local Anesthetic Systemic Toxicity: 2020 Checklist. Reg Anesth Pain Med 2021;46:81.
Landmark trials cited
- ARDSNet ARMA — NEJM 2000 (6 mL/kg)
- PROSEVA — NEJM 2013 (proning)
- ACURASYS — NEJM 2010; ROSE — NEJM 2019 (NMB in ARDS)
- OSCILLATE — NEJM 2013 (HFOV harm)
- FLORALI — NEJM 2015 (HFNC)
- ABC trial — Lancet 2008 (SAT/SBT)
- TracMan — JAMA 2013 (tracheostomy timing)
- SOAP II — NEJM 2010 (dopamine vs NE)
- VASST — NEJM 2008; ATHOS-3 — NEJM 2017
- ADRENAL & APROCCHSS — NEJM 2018 (steroids)
- NICE-SUGAR — NEJM 2009
- PROPPR — JAMA 2015; CRASH-2 — Lancet 2010; CRASH-3 — Lancet 2019
- TRICC — NEJM 1999; TRISS — NEJM 2014; MINT — NEJM 2023
- MENDS — JAMA 2007; SEDCOM — JAMA 2009; MIND-USA — NEJM 2018
- STARRT-AKI — NEJM 2020; BICAR-ICU — Lancet 2018; PRESERVE — NEJM 2018
- DOSE — NEJM 2011 (diuretics)
- EPaNIC — NEJM 2011; CALORIES — NEJM 2014; EDEN — JAMA 2012
- STOP-IT — NEJM 2015 (abx duration IAI)
- SUP-ICU — NEJM 2018
- TTM — NEJM 2013; TTM2 — NEJM 2021
- ESETT — NEJM 2019; RAMPART — NEJM 2012
- INTERACT-2 — NEJM 2013; ATACH-2 — NEJM 2016; PATCH — Lancet 2016
- RESCUEicp — NEJM 2016; CRASH — Lancet 2004 (steroids in TBI)
- DEXA-ARDS — Lancet Respir Med 2020
- CONFIRM — NEJM 2021 (terlipressin)
- WATERFALL — NEJM 2022 (pancreatitis fluids)
- Keystone ICU Project — NEJM 2006 (CLABSI bundle)
Reference texts & drug references
- Marino PL. Marino's The ICU Book, 4th ed. Wolters Kluwer, 2014.
- Gilbert DN, et al. The Sanford Guide to Antimicrobial Therapy, 2025.
- Nelson LS, et al. Goldfrank's Toxicologic Emergencies, 11th ed. McGraw-Hill, 2019.
- Lexicomp / UpToDate drug monographs and FDA package inserts (accessed 2026).
- Surgical Critical Care Evidence-Based Medicine Guidelines, surgicalcriticalcare.net (Orlando Regional Medical Center).
- American Board of Surgery. Surgical Critical Care Certifying Examination Content Outline. absurgery.org