Common icu drugs
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I now have enough information from the textbooks to compile a thorough answer. Here is a structured reference on common ICU drugs:
Common ICU Drugs
1. Vasopressors & Inotropes
These are used to maintain mean arterial pressure (MAP) >65 mmHg in shock states.
| Drug | Mechanism | Key Use | Notes |
|---|---|---|---|
| Norepinephrine | Alpha-1 + Beta-1 agonist | First-line vasopressor in septic/distributive shock | Titrate to MAP >65 mmHg |
| Vasopressin | V1 receptor agonist (vasoconstriction) | Added to norepinephrine in refractory shock | 0.03-0.04 units/min fixed dose |
| Dopamine | Dose-dependent (dopaminergic, beta, alpha) | No longer preferred - higher arrhythmia risk vs. norepinephrine | Largely replaced by norepinephrine |
| Epinephrine | Alpha + Beta agonist | Anaphylaxis, refractory shock | Also used as vasopressor + inotrope |
| Dobutamine | Beta-1 selective inotrope | Cardiogenic shock, low cardiac output | Does not raise BP alone; add vasopressor if hypotensive |
- Goldman-Cecil Medicine, 9780323930345: Norepinephrine - titrate to MAP >65 mmHg; hydrocortisone 50 mg IV q6h while vasopressor-dependent
2. Sedatives & Hypnotics
Used for ventilator synchrony, anxiety, and procedures. The goal is minimal sedation with daily sedation holidays.
| Drug | Class | Onset | Key Feature |
|---|---|---|---|
| Propofol | Alkylphenol sedative-hypnotic | ~40 sec | Short-acting, allows rapid wean; risk of propofol infusion syndrome (PRIS) with prolonged high-dose use |
| Midazolam | Benzodiazepine | 2-5 min | Longer context-sensitive half-life; accumulates; associated with more delirium |
| Dexmedetomidine | Alpha-2 agonist | 15-30 min | Anxiolytic + analgesic; does NOT cause respiratory depression; reduces delirium vs. midazolam/propofol; shorter ICU/ventilator duration |
| Ketamine | NMDA antagonist | <1 min (IV) | Dissociative; useful in bronchospasm, hemodynamically unstable patients; preserves airway reflexes |
| Lorazepam | Benzodiazepine | 5-10 min | Longer half-life; often used for alcohol withdrawal |
- Sabiston Textbook of Surgery: Dexmedetomidine noninferior to midazolam/propofol for sedation and associated with shorter mechanical ventilation duration
- Morgan & Mikhail's Clinical Anesthesiology: Propofol avoided for prolonged sedation due to PRIS concerns
- Daily sedation interruptions are now standard of care for all mechanically ventilated ICU patients
3. Analgesics
Analgesia-first (analgo-sedation) is the current standard.
| Drug | Class | Notes |
|---|---|---|
| Fentanyl | Opioid | Fastest onset (0.5 min IV); shortest half-life (0.5-1 h); preferred for infusions |
| Morphine | Opioid | 5-10 min onset (IV); histamine release; avoid in renal failure (active metabolites) |
| Hydromorphone | Opioid | More potent than morphine; 15-30 min onset; fewer active metabolites |
| Ketamine | NMDA antagonist | Opioid-sparing; useful in pain crises |
| Ketorolac | NSAID (COX inhibitor) | Reduces opioid use by up to 50%; max 5 days (bleeding/AKI risk) |
| Acetaminophen | Non-opioid analgesic | Safe, opioid-sparing; use IV in intubated patients |
| Naloxone | Opioid antagonist | Reverses opioid toxicity/respiratory depression; shorter half-life than most opioids - repeat doses often needed |
Opioid equivalences (relative to oral morphine 1 mg):
-
IV morphine = 0.3 mg
-
IV fentanyl = 0.003 mg
-
Oral hydromorphone = 0.2 mg
-
Sabiston Textbook of Surgery, 9780443124341
4. Neuromuscular Blocking Agents (NMBAs)
Used for ventilator dyssynchrony, refractory ICP elevation, ARDS, and status epilepticus.
| Drug | Duration | Notes |
|---|---|---|
| Succinylcholine | Ultra-short (~10 min) | Depolarizing; RSI agent; contraindicated in hyperkalemia, burns, crush injury >48h |
| Rocuronium | Intermediate (~45-70 min) | Non-depolarizing; preferred for RSI when succinylcholine contraindicated; reversed by sugammadex |
| Vecuronium | Intermediate | Non-depolarizing; infusion in ICU |
| Cisatracurium | Intermediate | Hoffman elimination - safe in liver/renal failure; preferred for continuous ICU infusions |
- Always use with adequate sedation + analgesia. Routine use is discouraged; reserved for specific indications.
5. Anticoagulants
| Drug | Use | Notes |
|---|---|---|
| Unfractionated heparin (UFH) | DVT prophylaxis, therapeutic anticoagulation, CRRT circuit | Reversible with protamine; monitor with aPTT; risk of HIT |
| LMWH (enoxaparin) | DVT prophylaxis (preferred), treatment | More predictable; once or twice daily SC; monitor anti-Xa in renal failure |
| Fondaparinux | VTE prophylaxis/treatment | HIT alternative; no protamine reversal |
- Goldman-Cecil Medicine: Thromboprophylaxis with low-molecular-weight heparin is evidence-based in mechanically ventilated ICU patients
6. Antimicrobials
Broad-spectrum coverage empirically, narrowed once culture data returns (antimicrobial stewardship).
| Category | Examples | Common ICU Indications |
|---|---|---|
| Beta-lactams | Piperacillin-tazobactam, meropenem, cefepime | Pneumonia (VAP/HAP), intraabdominal sepsis, febrile neutropenia |
| Glycopeptides | Vancomycin | MRSA coverage, gram-positive infections |
| Antifungals | Fluconazole, micafungin | Invasive candidiasis (esp. post-abdominal surgery, immunocompromised) |
| Antivirals | Acyclovir | HSV encephalitis; CMV in transplant |
| Aminoglycosides | Gentamicin, amikacin | Synergy in severe gram-negative infections; nephrotoxic - monitor levels |
7. Stress Ulcer Prophylaxis
| Drug | Dose | Notes |
|---|---|---|
| Pantoprazole (PPI) | 40 mg IV daily | Reduces GI bleeding risk; does NOT reduce mortality |
| H2 blockers (Famotidine) | 20 mg IV q12h | Alternative to PPI; may be preferred to reduce C. difficile risk |
- Goldman-Cecil Medicine: "Stress ulcer prophylaxis (e.g., pantoprazole 40 mg IV daily) can reduce the risk of gastrointestinal bleeding but not overall complications or mortality"
8. Insulin
- Target blood glucose 140-180 mg/dL in most ICU patients
- IV insulin infusion allows tighter control than subcutaneous
- Intensive insulin therapy targeting normoglycemia increases hypoglycemia risk and is NOT recommended
9. Corticosteroids
| Drug | Indication | Dose |
|---|---|---|
| Hydrocortisone | Vasopressor-refractory septic shock | 50 mg IV q6h (200 mg/day) while vasopressor-dependent |
| Methylprednisolone | Moderate-severe ARDS, acute exacerbation of COPD/asthma | Varies by indication |
| Dexamethasone | Raised ICP, meningitis, COVID-19 on O2 | 6 mg IV daily for 10 days in COVID-19 (RECOVERY trial) |
10. Anti-Delirium Agents
| Drug | Class | Notes |
|---|---|---|
| Haloperidol | Typical antipsychotic | Dopamine D2 blocker; used for hyperactive delirium/agitation; risk of extrapyramidal effects, QTc prolongation |
| Quetiapine / Olanzapine | Atypical antipsychotics | Less extrapyramidal side effects; evidence for delirium treatment is limited |
| Dexmedetomidine | Alpha-2 agonist | Reduces delirium incidence vs. other sedatives |
- Sabiston Textbook: A 2018 Cochrane review showed antipsychotics have no effect on delirium severity or mortality. Non-pharmacologic prevention (sleep/wake cycle, reorientation) remains the most effective strategy.
Quick Reference Summary
| Category | First-Line Agent |
|---|---|
| Vasopressor | Norepinephrine |
| Sedation | Propofol or Dexmedetomidine |
| Analgesia | Fentanyl (infusion) |
| NMBA (infusion) | Cisatracurium |
| VTE prophylaxis | LMWH (enoxaparin) |
| Stress ulcer | Pantoprazole 40 mg IV daily |
| Septic shock corticosteroid | Hydrocortisone 50 mg q6h |
| Glucose control | IV insulin (target 140-180 mg/dL) |
| Delirium prevention | Non-pharmacologic (+ dexmedetomidine) |
Sources: Goldman-Cecil Medicine, Sabiston Textbook of Surgery, Morgan & Mikhail's Clinical Anesthesiology, Miller's Anesthesia (10e)
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