Common Medications

Purpose: continuous infusion used for anesthesia, sedation, and severe agitation. Generally not advised as first-line sedative, but appropriate in some situations:

• Seizure management

• EtOH withdrawal

• Fall back option if Propofol or Precedex are contributing to hypotension or bradycardia

Onset: 1-3min

Duration: 30-60min.

• Versed produces unpredictable awakening and time to extubation when infusions continue longer than 48-72 hours

Dosage:

• Initial: 0.01-0.05 mg/kg;

• Maintenance: 0.02 mg/kg/hr

• Max: 2-10mg/hr.

Concerns: Use of versed is associated with longer ventilation times and longer LOS in ICU. It is the #1 delirium-causing medication.

Side Effects that may impact mobility: Excessive somnolence (1.6%), Cardiac arrest, Involuntary movement, Apnea (15.4%)

Purpose: decreases the water and Na reabsorption in the renal tubule causing a reduction in ICP and cerebral edema. Decreases blood viscosity, plasma expansion, and cerebral O2 delivery, causing cerebral vasoconstriction. Osmotic gradient across blood-brain barrier moves fluid from the parenchyma into the intravascular space. Works as an osmotic diuretic, moving fluid from intracellular space to extracellular diuretic effect

Onset of action: 15-30 min

Duration: 1.5-6 hours

Dosing: Effect is dose dependent; 0.25-2 g/kg/dose

Side effects: hyponatremia, AKI, tachycardia, hypotension with hypovolemia

Other side effects that may affect mobility: chest pain, peripheral edema, dizziness, HA

Purpose: Uses an osmotic gradient to shift fluid from intracellular space to interstitial and intravascular space to manage cerebral edema. Can be bolus or continuous infusion. Rapid onset, usually see effects in 5 minutes, can last 12 hours

Adverse side effects: electrolyte imbalances, Metabolic acidosis, Acute kidney injury (AKI), Coagulopathies, Hypotension

Onset of action: Oral IR 30-60min, ER 90min. IV 2min

Duration of action: Oral IR 3-4hrs, ER 12hrs. IV 2-4hrs.

Concerns: Respiratory depression, nausea, constipation, marked hypotension, accumulation in severe liver failure, accumulation of toxic metabolites in renal failure, neuroexcitation (seizures)

Dosage: 2-100 mcg/kg dependent on pain level, size/weight, and desired level of analgesia/anesthesia

Onset of Action: 7-8 min (bolus)

Duration of Action: 30-60 for bolus but elimination half-life is 2 hours and when used as part of long-term sedation may take longer as it is fat soluble

Concerns: Respiratory depression, nausea, constipation, bradycardia, hypotension, skeletal muscle rigidity at high bolus doses (> 100-200 mcg), accumulation in severe hepatic failure, confusion, somnolence

*Has to be weaned slowly. The symptoms of withdrawal are tachycardia, hypertension and diaphoresis. Also important to keep in mind the high likelihood of bowel slowing.

Onset of action: PO 30min. IV 1-2min.

Duration of action: PO 4hrs. IV ~2hrs.

Concerns: Respiratory depression, bradycardia, hypotension, nausea, constipation

Onset of action: IR 30-60min; ER variable.

Duration of action: IR 3-4hrs; ER 12hrs

Side Effects/Concerns: Respiratory depression, nausea, constipation, hypotension, bradycardia, drug-drug interactions

Onset of action: PO ~1hr. IV 30min

Duration of action: 4-8hrs

Side Effects/Concerns: Respiratory depression, nausea, constipation, extremely long half-life (up to 150 hrs but that is not same as duration of action), QTc prolongation and risk of arrhythmias, serotonin syndrome

Dosage: 0.03 mg/kg every 40-50 minutes OR 0.03 mg/kg every 50-60 minutes OR maintenance infusing 3 mcg/kg/minute. Reduce to 1-2 mcg/kg/minute as needed

Dosage: 0.01-0.012 mg/kg/min for continuous infusion

Purpose: Sedation and adjuvant analgesic without respiratory depression.

• Has been shown to increase the amount of ICU days without delirium.

• Creates light to moderate sedation and has support to preserve the sleep/wake cycle.

• Patient is usually more awake vs other sedatives. Not recommended for deep sedation

• Good to use as part of the weaning process from propofol as patients are weaned from the vent. Important to know that 10-15% of patients do not respond at all, for unknown reasons.

Onset: 10-15min

Duration of Effect: 1-2 hrs. Patients may be easily roused, able to follow commands, and may fall back quickly into deeper sedation once the rousing stimulus is removed.

Dosage: initial loading dose: 1 mcg/kg over 10 minutes. Maintenance 0.2-.07 mcg/kg/hr. Can’t really be given in bolus because of the risk for bradycardia.

Side Effects: initial bolus injection is associated with vasoconstrictive effects, causing bradycardia and HTN. Continuous infusion is associated with hypotension secondary to vasodilation caused by central sympatholysis. A-fib and tachycardia also reported

Other Side Effects that may affect mobility: Apnea, Bronchospasm

Purpose: Primary medication used on Neuro ICU. Rapid wean off effect. Can be decreased for neuro checks.

Onset: 10 seconds

Duration of Effect: 5-20 min. Fat-soluble, so resources vary on wake-up times based on time under sedation and level of Propofol delivered. Leaves the CNS first, so does stop working fairly fast. Patients may be more aroused very quickly once the infusion is turned off or down.

• Light sedation <48 hours: 3-10 min

• Light sedation <72 hours: less than 35 min

• Deep sedation 24 hours: 25 hours

• Deep sedation 7-14 days: 3 days

Dosage: Range 5-80mg/kg/min. In a healthy younger adult (<55 y/o): 6-12 mg/kg/hr. Geratric or debilitated: 3-6 mg/kg/hr

• Low: 0-30mg/kg/min

• Moderate: 30-50 mg/kg/min

• High: 50-80 mg/kg/min

Precautions: Consider dose and ability to follow commands. Can the patient tolerate a lower dose? If can decrease, should have a quick impact/change in arousal.

Side Effects: dystonia or choreiform movements; bradycardia, hypotension, decreased cardiac output, hyperlipidemia, apnea, decreased respiratory drive, respiratory acidosis, Propofol infusion syndrome. May also decrease systemic vascular resistance, myocardial blood flow, cerebral blood flow, ICP, and oxygen consumption.

Pulmonary Side Effects: Respiratory depressant, frequently producing apnea that may persist for longer than 60 seconds, may produce significant decreases in respiratory rate, minute volume, tidal volume, mean inspiratory flow rate, and functional residual capacity

Additional Concerns: Hypertriglyceridemia may result from prolonged administration and can cause pancreatitis. Propofol causes amnesia so weaning can result in fear and anxiety. It is prepared in a lipid emulsion so it does contain about 100 calories in every bottle.

Propofol Infusion Syndrome

• Rare and poorly understood. Thought to be due to biomedical changes caused by propofol and underlying conditions in the critically ill

• Risk factors: hypoxia, severe neurological injury, sepsis, use of vasoconstrictors, steroids, inotropes, and/or prolonged infusions or Propofol >5mg/kg/hr for > 48 hrs.

• Symptoms: severe metabolic acidosis, hyperkalemia, lipemia, rhabdomyolysis, heptatomegaly and elevated liver enzymes, renal failure, EKG changes, and heart failure

• Treatment: stop using Propofol and supportive care

Purpose: Part of multimodal pain management and used more often to take pressure off of nation opioid shortage. Higher doses help to decrease other sedative requirements and lower doses help to decrease other opioid requirements.

Onset of action: IV 30 seconds. IM 3-4min.

Duration of action: IV 5-10min. IM 12-25min.

Side Effects: Hypertension, tachycardia, dissociative anesthetic at higher doses, hallucinations, apnea with rapid administration of large bolus doses, nausea

Indication: Hypotension. Causes peripheral vasoconstriction, inotropic stimulation of the heart, and coronary artery vasodilation. Preferred initial agent to treat septic shock.

• For about 90% of patients, this is the first choice pressor.

Dose:

• Low: 0.03 mcg/kg/min    

• Moderate: 0.2 mcg/kg/min        

• High: 0.5 mcg/kg/min

Hemodynamic Effects: Mild increase or no impact on HR

Other Side Effects that may affect mobility: Tissue necrosis, confusion, headache, tremor, anxiety, restlessness

Indication: Most often used for the treatment of anaphylaxis, second-line agent in septic shock, and management of hypotension s/p CABG.

• It may not be a good sign, clinically, if this is being used.

Dose:

• Low: 0.2 μg/kg/min

• Moderate: 0.8 μg/kg/min

• High: 2 μg/kg/min

Hemodynamic Effects: Increased CO, with decreased SVR and variable effects on the MAP. May cause increased HR, dysrhythmias, HTN, V-Fib.

Other Side Effects that may affect mobility: Asthenia, dizziness, headache, tremor, difficulty breathing/pulmonary edema, cerebral hemorrhage

Indication: Most often used to treat hypotension due to sepsis or cardiac failure

Dose Determines Hemodynamic Effects:

• Low: 1-2 mcg/kg/min

  • Selective vasodilation in renal, mesenteric, cerebral, coronary beds. No impact on HR. Possible hypotension

• Moderate: 5-10 mcg/kg/min

  • Increases CO (increase SV with variable effects on HR but likely increased HR)

• High: >10 mcg/kg/min

  • Vasoconstriction with an increased systemic vascular resistance (increased HR)

Other side effects that may affect mobility: dyspnea, HA

Indication: Hypotension in hyperdynamic sepsis, neurologic disorders, anesthesia-induced hypotension. Results in vasoconstriction with minimal cardiac inotropy or chronotropy.

Dose:

• Low = 0.5 mcg/kg/min

• Moderate = 2

• High = 5

Hemodynamic Effects: severe bradycardia, V-Tach

Other Side Effects that may affect mobility: HA, metabolic acidosis, restlessness

Indication: Vasodilatory shock/septic shock. Vasopressin may be used in patients with refractory shock despite adequate fluid resuscitation with the use of high-dose norepinephrine and dopamine.

• Most notorious for causing distal tissue necrosis.

Dose:

• Low: 1.2 unit/hr

• High: 2.4 unit/hr

Hemodynamic Effects: decreased HR, arrhythmias, cardiac arrest, CO, angina, myocardial ischemia, and peripheral constriction