I now have comprehensive data from LITFL (Life in the Fast Lane - a gold-standard critical care reference) and the Augusta University Adult Critical Care IV Titration Protocol. Here is a full, detailed reference guide:
ICU Infusions: Complete Reference Guide
Overview
ICU infusions (also called "drips") are continuous intravenous (IV) medications delivered via syringe or infusion pump. They require precise preparation, concentration control, and ongoing titration to physiologic goals. They are typically administered through a central venous access device (CVAD) - although vasopressors may be given peripherally short-term via 18G or 20G cannula proximal to the wrist.
1. VASOPRESSORS & INOTROPES
These are the most common ICU drips, used for shock states and hemodynamic instability.
Norepinephrine (Noradrenaline) - First-line vasopressor for septic shock
| Parameter | Detail |
|---|
| Preparation | 4 mg in 100 mL 5% dextrose = 40 mcg/mL |
| Dose range | 0.01 - 1 mcg/kg/min |
| Infusion rate | 1 - 20 mL/h (titrate to effect) |
| Indication | Septic shock, distributive shock, post-cardiac surgery vasoplegia |
| Access | Central line preferred; peripheral short-term acceptable |
| Titration | Titrate to MAP ≥ 65 mmHg (or per provider goal) |
| Notes | Preferred over dopamine - lower arrhythmia risk. Dilute in D5W, not normal saline (NS). |
How to make: Draw 4 mg norepinephrine from vials → add to 100 mL D5W bag → label clearly with concentration (40 mcg/mL). Protect from light.
Epinephrine (Adrenaline) - Anaphylaxis, refractory shock, cardiac arrest adjunct
| Parameter | Detail |
|---|
| Preparation | 4 mg in 100 mL D5W = 40 mcg/mL |
| Dose range | 0.01 - 0.5 mcg/kg/min |
| Indication | Anaphylactic shock, refractory septic shock, cardiogenic shock |
| Notes | Causes hyperglycemia and lactic acidosis. Monitor lactate - do NOT use lactate as a resuscitation endpoint when on epinephrine. |
How to make: Draw 4 mg epinephrine (4 x 1 mg/1 mL ampoules) → add to 100 mL D5W → label 40 mcg/mL.
Dopamine - Less preferred vasopressor (high arrhythmia risk)
| Parameter | Detail |
|---|
| Preparation | 200 mg in 50 mL D5W = 4 mg/mL (or 400 mg in 250 mL D5W) |
| Dose range (low) | 2-5 mcg/kg/min - renal/splanchnic dilation |
| Dose range (mid) | 5-10 mcg/kg/min - inotropy (β1 effect) |
| Dose range (high) | 10-20 mcg/kg/min - vasoconstriction (α1 effect) |
| Notes | Higher risk of atrial fibrillation vs. norepinephrine. SOAP II trial showed dopamine inferior to norepinephrine in shock. |
Vasopressin (Arginine Vasopressin) - Add-on to norepinephrine in septic shock
| Parameter | Detail |
|---|
| Preparation | Vasopressin 20 units in 100 mL NS = 0.2 units/mL |
| Dose | Fixed: 0.03 - 0.04 units/min (1.8 - 2.4 units/hour) - do not titrate up |
| Indication | Septic shock - added when norepinephrine dose is escalating (≥ 0.25 mcg/kg/min) |
| Notes | Spares catecholamine dose. Do not titrate. |
How to make: Draw 20 units (1 vial) vasopressin → add to 100 mL NS → mix → label 0.2 units/mL.
Phenylephrine - Pure alpha agonist (no inotropy)
| Parameter | Detail |
|---|
| Preparation | 10 mg in 500 mL D5W = 20 mcg/mL (or 160 mcg/mL concentrated) |
| Dose range | 0.1 - 10 mcg/kg/min |
| Indication | Vasodilatory shock, intraoperative hypotension, avoiding tachycardia |
| Notes | Useful when tachycardia is present and inotropy not needed. Can cause reflex bradycardia. |
Dobutamine - Inotrope (positive inotropy without vasoconstriction)
| Parameter | Detail |
|---|
| Preparation | 250 mg in 100 mL NS = 2.5 mg/mL |
| Dose range | 2.5 - 10 mcg/kg/min |
| Infusion rate | 4.2 - 16.8 mL/h (for 70 kg patient) |
| Indication | Cardiogenic shock, low cardiac output states, decompensated heart failure |
| Notes | May worsen hypotension if given alone in hypovolemia - often combined with norepinephrine. |
Milrinone - Phosphodiesterase-III inhibitor (inodilator)
| Parameter | Detail |
|---|
| Preparation | 20 mg in 100 mL NS = 200 mcg/mL |
| Loading dose | 50 mcg/kg over 10 min (rarely used due to hypotension risk) |
| Maintenance | 0.375 - 0.75 mcg/kg/min (5 - 15 mL/h) |
| Indication | Acute decompensated heart failure, pulmonary hypertension in cardiogenic shock |
| Notes | Causes vasodilation - monitor BP. Renally cleared, reduce in AKI. |
Metaraminol - Short-acting alpha agonist
| Parameter | Detail |
|---|
| Preparation | 30 mg in 60 mL NS = 0.5 mg/mL |
| Bolus | 0.5 - 1 mg every 2-5 mins |
| Infusion | 0.5 - 10 mg/h |
| Notes | Consider switching to norepinephrine if rate > 10 mL/h. |
2. SEDATION & ANXIOLYTICS
Used in mechanically ventilated patients. Target RASS (Richmond Agitation-Sedation Scale) score as ordered.
Propofol - First-line sedative in ICU (intubated patients)
| Parameter | Detail |
|---|
| Preparation | Neat (pre-made): 1% = 1000 mg in 100 mL (10 mg/mL). Do NOT dilute further. |
| Bolus | 0.5 - 1 mg/kg for short procedures |
| Induction | 0.5 - 2 mg/kg IV |
| Maintenance (ICU) | 1 - 4 mg/kg/h = ~1 - 25 mL/h (70 kg patient) |
| Starting rate | 5 mcg/kg/min; titrate every 30 min |
| Max dose | 80 mcg/kg/min (to avoid propofol infusion syndrome - PRIS) |
| Indication | Sedation of intubated ICU patients; also status epilepticus |
| Notes | Monitor triglycerides (lipid vehicle). Change infusion line every 12 hours (infection risk). Watch for PRIS: metabolic acidosis, rhabdomyolysis, cardiac failure. |
Midazolam - Benzodiazepine sedation (longer-acting)
| Parameter | Detail |
|---|
| Preparation | 50 mg in 50 mL NS = 1 mg/mL |
| Bolus | 0.1 mg/kg (up to 5 mg) for procedural sedation |
| Infusion | 0.03 - 0.2 mg/kg/h = 0.5 - 10 mg/h |
| Indication | Sedation, seizure control, alcohol withdrawal |
| Notes | Accumulates with prolonged use (active metabolite). Associated with delirium. Prefer propofol or dexmedetomidine for long-term ICU sedation. |
Dexmedetomidine (Precedex) - Alpha-2 agonist sedation - cooperative/awake sedation
| Parameter | Detail |
|---|
| Preparation | 200 mcg in 50 mL NS = 4 mcg/mL |
| Loading dose | 0.5 - 1 mcg/kg over 10-20 min (often omitted in ICU to avoid bradycardia/hypotension) |
| Starting rate | 0.2 - 0.4 mcg/kg/h |
| Maintenance | 0.2 - 1 mcg/kg/h = 1 - 15 mL/h |
| Indication | Cooperative sedation (patient can follow commands), procedural sedation, ventilator weaning, agitated delirium, alcohol withdrawal |
| Notes | Does NOT cause respiratory depression - patient can be extubated without stopping. Monitor for bradycardia and hypotension. |
How to make: Draw 200 mcg dexmedetomidine (from 200 mcg/2 mL vial) → add to 48 mL NS in 50 mL syringe → mix → label 4 mcg/mL.
Ketamine - Dissociative anesthetic - analgesic-sedative
| Parameter | Detail |
|---|
| Preparation | 600 mg in 60 mL NS = 10 mg/mL |
| Procedural sedation | 0.1 - 0.3 mg/kg IV bolus |
| Analgesia infusion | 0.05 - 0.1 mg/kg/h |
| Sedation infusion | 0.2 mg/kg/h |
| RSI | 0.25 - 2 mg/kg IV push |
| Notes | Maintains airway reflexes, bronchodilator - useful in severe asthma, haemodynamically unstable patients. May cause emergence delirium - pair with benzodiazepine for procedures. |
3. ANALGESIA (OPIOIDS)
Pain-first approach (analgosedation) is the modern standard in ICU care. Treat pain before adding sedation.
Morphine
| Parameter | Detail |
|---|
| Preparation | 60 mg in 60 mL NS = 1 mg/mL |
| Bolus | 0.1 mg/kg or 2.5 - 5 mg aliquots |
| Infusion | 1 - 10 mg/h |
| Notes | Avoid in renal failure (active metabolite morphine-6-glucuronide accumulates). |
Fentanyl - Preferred opioid in ICU (especially renal failure)
| Parameter | Detail |
|---|
| Preparation | 1000 mcg (1 mg) in 50 mL NS = 20 mcg/mL |
| Bolus | 1 - 1.5 mcg/kg IV push |
| Infusion | 25 - 250 mcg/h (0.5 - 2 mcg/kg/h) |
| Notes | No active renal metabolites - safe in renal failure. Accumulates in fat with prolonged use. |
Remifentanil - Ultrashort-acting opioid (ester hydrolysis - organ-independent clearance)
| Parameter | Detail |
|---|
| Preparation | 5 mg in 100 mL NS = 50 mcg/mL (higher concentration for ICU) |
| ICU analgesia | 0.1 - 0.4 mcg/kg/min |
| Notes | Half-life ~3-10 min. No accumulation regardless of organ function. Excellent for neurological ICU (allows frequent neurological assessment). Causes opioid-induced hyperalgesia with prolonged use. |
Oxycodone
| Parameter | Detail |
|---|
| Preparation | 60 mg in 60 mL NS = 1 mg/mL |
| Bolus | 0.1 - 0.2 mg/kg or 0.5 - 2 mg aliquots |
| Infusion | 1 - 10 mg/h |
4. NEUROMUSCULAR BLOCKING AGENTS (NMBAs) - Paralytic Infusions
Used only with deep sedation (RASS -4 to -5). Never paralyze a patient who is not deeply sedated.
Rocuronium - Non-depolarizing NMBA
| Parameter | Detail |
|---|
| Preparation | Neat 5 mg/mL (supplied ready to use) |
| Starting rate | 8 mcg/kg/min |
| Range | 8 - 12 mcg/kg/min |
| Max | 12 mcg/kg/min |
| Titration | Titrate to train-of-four (TOF) goal |
| Notes | Use ideal body weight. Reversed by sugammadex. |
Cisatracurium - Preferred NMBA for prolonged ICU use (Hofmann elimination)
| Parameter | Detail |
|---|
| Preparation | 50 mg in 100 mL NS = 0.5 mg/mL |
| Infusion | 1 - 3 mcg/kg/min |
| Notes | Organ-independent degradation. Preferred in liver/renal failure. |
5. ANTIHYPERTENSIVES & VASODILATORS
Nicardipine (Cardene) - CCB - hypertensive emergency
| Parameter | Detail |
|---|
| Preparation | 0.1 mg/mL standard (0.2 mg/mL max) |
| Starting rate | 5 mg/h |
| Range | 5 - 15 mg/h |
| Max | 15 mg/h |
| Titration | Every 15 min |
| Indication | Hypertensive emergency, ischemic stroke (permissive hypertension management) |
Labetalol - Alpha + beta blocker
| Parameter | Detail |
|---|
| Preparation | 100 mg in 100 mL D5W = 1 mg/mL OR neat 300 mg in 60 mL = 5 mg/mL |
| Bolus | 0.25 - 0.5 mg/kg (up to 20 mg) over 2 min, repeat every 10 min |
| Infusion | 0.25 - 3 mg/kg/h (max 300 mg/day) |
| Indication | Hypertensive emergency, aortic dissection, eclampsia |
Nitroglycerin (GTN) - Venodilator - chest pain, pulmonary edema
| Parameter | Detail |
|---|
| Preparation | 200 mcg/mL standard concentration |
| Starting rate | 10 mcg/min |
| Range | 5 - 100 mcg/min |
| Max | 100 mcg/min (up to 400 mcg/min provider-driven) |
| Titration | Every 10 min |
| Indication | Acute chest pain (ACS), acute pulmonary edema, hypertensive emergency with LVF |
| Notes | Use non-PVC tubing (drug adsorbs to PVC). Do NOT use for isolated hypertension without cardiac indication. |
Sodium Nitroprusside (SNiP) - Potent vasodilator - hypertensive emergency
| Parameter | Detail |
|---|
| Preparation (central) | 50 mg in 100 mL D5W = 500 mcg/mL |
| Preparation (peripheral) | 50-100 mg in 500 mL D5W = 100-200 mcg/mL |
| Starting rate | 0.5 mcg/kg/min |
| Range | 0.5 - 10 mcg/kg/min |
| Titration | Adjust every 2-3 min by 1 mL/h |
| Notes | Metabolized to cyanide - do NOT exceed 72 hours or 10 mcg/kg/min. Monitor for cyanide toxicity (metabolic acidosis, tachyphylaxis). MUST wrap in foil - light sensitive. |
Esmolol - Ultra-short-acting beta-1 blocker
| Parameter | Detail |
|---|
| Preparation | Neat 600 mg in 60 mL = 10 mg/mL |
| Loading dose | 500 mcg/kg over 1 min |
| Starting infusion | 50 mcg/kg/min |
| Range | 50 - 200 mcg/kg/min |
| Titration | Repeat load + increase infusion by 50 mcg/kg/min every 3-4 min |
| Indication | Rapid rate control (AF, SVT), perioperative hypertension, aortic dissection (rate control) |
| Notes | Half-life ~9 min - easily titratable. |
6. ANTIARRHYTHMICS
Amiodarone - Broad-spectrum antiarrhythmic
| Parameter | Detail |
|---|
| Loading dose | 300 mg IV over 20-60 min (in D5W, NOT NS - precipitates) |
| Maintenance infusion | 900 mg in 500 mL D5W over 24 hours (~1 mg/min) |
| Indication | AF, VT, VF (after defibrillation) |
| Notes | Use glass bottles or polyolefin bags - precipitates in PVC over time. Peripheral infusion causes phlebitis - central line preferred. Incompatible with NS. |
Lidocaine (Lignocaine) - Ventricular arrhythmias
| Parameter | Detail |
|---|
| Preparation | 1% or 2% solution drawn into 60 mL syringe = 10 mg/mL (1%) or 20 mg/mL (2%) |
| Bolus | 1 mg/kg IV push (ALS/pain) |
| Infusion | 1 - 4 mg/min for 24 h = 6 - 24 mL/h (for 1% solution) |
| Indication | Ventricular tachycardia, adjunct analgesia |
7. INSULIN INFUSION - For Hyperglycemia / DKA / HHS
| Parameter | Detail |
|---|
| Preparation | 50 units regular insulin (Actrapid/Humulin R) in 50 mL NS = 1 unit/mL |
| Starting rate | 0.05 - 0.1 units/kg/h |
| Range | 0.5 - 10 units/h (protocol-driven) |
| Target glucose (ICU) | 140 - 180 mg/dL (7.8 - 10 mmol/L) per most protocols |
| Notes | Flush first 20-30 mL of the prepared infusion through the IV line to saturate tubing (insulin adsorbs to plastic tubing). Check glucose every 1-2 hours initially. Never stop abruptly in DKA without overlap with subcutaneous insulin. |
How to make: Draw 50 units insulin → add to 50 mL NS syringe → gently invert → label "1 unit/mL insulin." Prime (waste) the first 20 mL through IV tubing before connecting to patient.
8. ANTICOAGULATION INFUSIONS
Unfractionated Heparin (UFH)
| Parameter | Detail |
|---|
| Preparation | 25,000 units in 250 mL NS = 100 units/mL (or 20,000 units in 500 mL NS = 40 units/mL) |
| Starting rate | Weight-based: typically 18 units/kg/h after 80 units/kg bolus (per institutional protocol) |
| Monitoring | aPTT every 6 hours (target typically 60-100 sec, or anti-Xa 0.3-0.7) |
| Indication | VTE treatment/prophylaxis, ACS (STEMI/NSTEMI), mechanical heart valves, CVVHDF circuit anticoagulation |
| Notes | Reverse with protamine (1 mg per 100 units heparin given in last hour). |
Argatroban - Direct thrombin inhibitor (HIT)
| Parameter | Detail |
|---|
| Preparation | 250 mg in 250 mL NS = 1 mg/mL |
| Starting rate | 2 mcg/kg/min (reduce to 0.5 mcg/kg/min in liver failure) |
| Monitoring | aPTT every 2 hours initially; target 1.5-3x baseline |
| Indication | Heparin-induced thrombocytopenia (HIT), heparin allergy |
9. DIURETICS
Furosemide (Lasix)
| Parameter | Detail |
|---|
| Preparation | 250 mg in 250 mL NS = 1 mg/mL (or 500 mg/50 mL = 10 mg/mL) |
| Infusion range | 1 - 40 mg/h |
| Indication | Acute volume overload, pulmonary edema, oliguria |
| Notes | Protect from light. Monitor K+ and Mg2+ closely. |
Bumetanide (Bumex)
| Parameter | Detail |
|---|
| Preparation | 0.25 mg/mL standard concentration |
| Starting rate | 0.5 mg/h |
| Range | 0.5 - 3 mg/h |
| Max | 3 mg/h |
| Titration | Every 2 hours; titrate to urine output goal |
10. OTHER IMPORTANT ICU INFUSIONS
Sodium Bicarbonate - Severe metabolic acidosis / hyperkalemia / TCA overdose
| Parameter | Detail |
|---|
| Preparation | 8.4% sodium bicarbonate (1 mEq/mL), 50 mEq bolus OR 150 mEq in 1 L D5W |
| Indication | Severe metabolic acidosis (pH < 7.1), TCA overdose, hyperkalemia |
3% Hypertonic Saline - Raised intracranial pressure, severe hyponatremia
| Parameter | Detail |
|---|
| Preparation | Pre-made 3% NaCl |
| Rate | 10 - 50 mL/h (infusion) or 250-500 mL bolus for acute ICP crisis |
| Notes | Central line only. Monitor Na+ every 2-4 hours. Do NOT correct Na+ faster than 8-10 mEq/L per 24 hours (hyponatremia). |
Nimodipine - Cerebral vasospasm after subarachnoid hemorrhage (aSAH)
| Parameter | Detail |
|---|
| Preparation | Neat: 10 mg in 50 mL = 200 mcg/mL |
| Infusion | 20 mcg/kg/h OR 1 mL/h per 10 kg body weight for 21 days |
| Example | 70 kg patient = 7 mL/h |
| Notes | Use PVC-free tubing (absorbs to PVC). Monitor BP closely. |
Salbutamol (Albuterol) - Severe bronchospasm / hyperkalemia
| Parameter | Detail |
|---|
| Preparation | 5 mg in 50 mL NS = 100 mcg/mL |
| Loading dose | 4-5 mcg/kg over 10 min |
| Maintenance | 5 - 20 mcg/min = 3 - 12 mL/h |
| Indication | Severe asthma, hyperkalemia (intracellular K+ shift) |
Levosimendan - Calcium sensitizer / inodilator
| Parameter | Detail |
|---|
| Preparation | 12.5 mg in 250 mL D5W = 50 mcg/mL |
| Loading dose | 6 - 24 mcg/kg over 10 min |
| Maintenance | 1 - 14 mcg/min for 24 hours |
| Indication | Acute decompensated heart failure (especially where dobutamine ineffective) |
General Principles for ICU Infusion Preparation
Safety Checks (Before Every Infusion)
- 5 Rights: Right patient, right drug, right dose, right route, right time
- Two-nurse verification for high-alert medications (insulin, heparin, vasopressors, concentrated electrolytes)
- Verify concentration in pharmacy-prepared bags if available
- Label every syringe/bag with: drug name, concentration, total volume, date/time prepared, expiry, preparer initials
- Use a smart infusion pump with drug library (dose-error reduction software)
Preparation Rules
- Most vasopressors are diluted in D5W (not NS) unless otherwise specified
- Amiodarone must be in D5W (precipitates in NS)
- Nitroglycerin and nitroprusside require light protection (wrap in foil)
- Nitroprusside prepared solutions should be discarded after 4 hours if exposed to light
- Insulin requires line priming (flush first 20-30 mL to saturate tubing)
- Propofol bags must be changed every 12 hours (lipid emulsion - infection risk)
- Nimodipine must use PVC-free tubing
Access Routes
| Drug Type | Preferred Route |
|---|
| Vasopressors (all) | Central venous catheter (CVC) - short-term peripheral acceptable |
| Amiodarone | CVC preferred (phlebitis with peripheral) |
| Potassium > 40 mEq/L | Central only |
| Hypertonic saline (3%) | Central only |
| Propofol | Peripheral or central acceptable |
| Insulin | Peripheral acceptable |
Disclaimer: All infusion rates, concentrations, and protocols should be verified against your institution's drug library, pharmacist, and attending physician's orders. Doses vary by clinical indication, patient weight, renal/hepatic function, and individual response. This reference is educational and does not replace clinical judgment or local protocols.
