Acute Care Medication 2025

Tips: monitor vitals (BP, HR, RR, SpO₂), mental status, IV site (extravasation), labs (BMP, CBC, LFTs, troponin/CK if indicated), and any drug-specific labs noted below. A. Cardiovascular: Pressors & Inotropes

Norepinephrine (Levophed) — vasoplegic/hypotensive shock

• Use: Septic shock, pressor of choice.

• Watch: ↑BP/afterload → ischemia; tachyarrhythmias; skin/limb ischemia; extravasation necrosis. Monitor BP, lactate, urine output, peripheral perfusion.

Epinephrine — cardiac arrest, anaphylaxis, refractory shock

• Use: ACLS, anaphylaxis, severe shock.

• Watch: Tachyarrhythmias, myocardial ischemia, hyperglycemia, lactic acidosis. Monitor ECG, glucose, lactate.

Vasopressin (Pitressin) — adjunct vasopressor in distributive shock

• Use: Add-on for vasoplegia (septic shock), CPR adjunct.

• Watch: Ischemia (digital, mesenteric, coronary), hyponatremia. Monitor urine, lactate/perfusion, Na.

Phenylephrine — pure α-agonist

• Use: Neurogenic/vasodilatory hypotension with tachyarrhythmias or to increase BP without ↑HR.

• Watch: Reflex bradycardia, ↓CO/organ perfusion, ischemia. Monitor BP, HR, urine output.

Dopamine - historically for renal/pressor effects (less used)

• Use: Selected bradycardic/hypotensive patients (dose-dependent).

• Watch: Tachyarrhythmias, ischemia; avoid in cardiogenic shock if possible. Monitor ECG, perfusion.

Dobutamine-inotropic support for low-output states

• Use: Cardiogenic shock with adequate BP; low CO with high SVR.

• Watch: Tachyarrhythmias, hypotension (β2 vasodilation), myocardial ischemia. Monitor BP, ECG, urine output, lactate.

Milrinone — inodilator (PDE-3)---Phosphodiesterase 3

• Use: Acute decompensated HF with low CO, RV failure, bridge therapy.

• Watch: Hypotension, arrhythmias; renal dosing required. Monitor BP, ECG, renal function.

B. Antiarrhythmics & Rate Control

Amiodarone

• Use: Ventricular tachyarrhythmias, atrial fibrillation (rate/rhythm).

• Watch: Hypotension, bradycardia, QT prolongation; long-term: pulmonary fibrosis, thyroid and liver dysfunction. Monitor ECG, LFTs, TSH, CXR if prolonged.

Lidocaine (IV)

• Use: Ventricular arrhythmias (VT/VF).

• Watch: CNS toxicity (confusion, seizures), hypotension. Monitor neuro exam, ECG.

Adenosine

• Use: SVT termination (AVNRT).

• Watch: Transient asystole, bronchospasm (asthma/COPD), chest discomfort. Monitor continuous ECG and airway.

Beta-blockers (esmolol, metoprolol)

• Use: Rate control (AF), HTN, post-MI.

• Watch: Bradycardia, hypotension, bronchospasm (asthma/COPD), worsening HF. Monitor HR, BP, bronchospasm.

Diltiazem / Verapamil

• Use: Rate control for AF/flutter (non-acute decompensated HF).

• Watch: Hypotension, bradycardia, heart block, negative inotropy (avoid in HFrEF). Monitor ECG, BP.

C. Sedation & Analgesia

Propofol

• Use: Sedation for intubated patients, induction.

• Watch: Hypotension, respiratory depression; high-dose/prolonged → Propofol Infusion Syndrome (metabolic acidosis, rhabdo). Monitor BP, TGs, acid-base.

Dexmedetomidine

• Use: Light sedation (ICU), agitation control.

• Watch: Bradycardia, hypotension. Monitor HR, BP, sedation score.

Benzodiazepines (midazolam, lorazepam)

• Use: Procedural sedation, seizures, alcohol withdrawal.

• Watch: Respiratory depression, delirium, accumulation (hepatic/renal). Monitor RR, O₂, sedation, liver/renal function.

Opioids (fentanyl, morphine, hydromorphone, remifentanil)

• Use: Analgesia, sedation adjunct.

• Watch: Respiratory depression, hypotension, bradycardia, ileus, urinary retention, pruritus; fentanyl → chest wall rigidity (rare). Monitor RR, SpO₂, pain scores, sedation.

D. Neuromuscular Blockers & Reversal

Succinylcholine

• Use: Rapid sequence intubation.

• Watch: Hyperkalemia (avoid in burns, crush, neuromuscular disease, prolonged immobilization), malignant hyperthermia trigger, bradycardia. Monitor K+, temps, end-tidal CO₂.

Rocuronium / Vecuronium / Cisatracurium

• Use: Paralysis for intubation/ventilation.

• Watch: Prolonged blockade in hepatic/renal failure (except cisatracurium preferred in organ failure); residual neuromuscular weakness. Monitor TOF, ventilator synchrony, sedation depth.

Sugammadex / Neostigmine (+anticholinergic)

• Use: Reversal of non-depolarizing block.

• Watch: Sugammadex: anaphylaxis, bradycardia, renal impairment; neostigmine: bradycardia, bronchospasm, secretions. Monitor TOF, HR, breathing.

E. Antimicrobials (common ICU agents)

Always tailor to culture and local antibiogram. Monitor renal dosing, troughs/levels, and adverse events.

Vancomycin

• Use: MRSA, severe Gram-positive infections.

• Watch: Nephrotoxicity, ototoxicity; “red man” infusion reaction. Monitor trough/area-under-curve, creatinine.

Piperacillin–Tazobactam / Cefepime / Meropenem

• Use: Broad-spectrum coverage for hospital/ventilator-associated infections.

• Watch: AKI (esp. pip-tazo + vanc), neurotoxicity (cefepime in renal failure), seizures (carbapenems). Monitor renal fx, neuro status.

Linezolid

• Use: VRE, MRSA alternatives.

• Watch: Thrombocytopenia, serotonin syndrome with SSRIs, neuropathy with long use. Monitor CBC, serotonin symptoms.

Daptomycin

• Use: MRSA, VRE (not for pneumonia).

• Watch: Myopathy, ↑CPK; avoid in pneumonia. Monitor CPK, muscle pain.

F. Anticoagulants & Antiplatelets

Unfractionated Heparin (IV/SC)

• Use: VTE prophylaxis/tx, ACS protocols, line patency.

• Watch: Bleeding, HIT. Monitor aPTT (or anti-Xa), platelets.

Enoxaparin (LMWH)

• Use: VTE prophylaxis/tx.

• Watch: Renal dose adjust; bleeding; avoid in active bleeding/HIT history. Monitor anti-Xa if needed.

Warfarin

• Use: Long-term VTE/AF anticoagulation (bridging when needed).

• Watch: INR monitoring, bleeding, multiple drug interactions. Reversal: Vit K, PCC/FFP.

DOACs (apixaban, rivaroxaban) — inpatient cautions

• Use: VTE/AF when appropriate.

• Watch: Renal dosing, bleeding; reversal agents limited (andexanet alfa). Monitor renal function, bleeding.

Antiplatelets (ASA, clopidogrel, ticagrelor)

• Use: ACS, stent protocols, secondary prevention.

• Watch: Bleeding—timing around procedures. Monitor bleeding, platelet counts.

G. Antithrombotic Reversal / Management

Protamine sulfate-- heparin reversal

• Watch: Hypotension, anaphylaxis (fish allergy risk). Monitor BP, coag testing.

Vitamin K / PCC / FFP — warfarin reversal

• Watch: Volume overload with FFP, thrombosis risk with PCC.

H. Diuretics & Volume Management

Furosemide / Bumetanide / Torsemide

• Use: Volume overload, pulmonary edema.

• Watch: Hypovolemia, electrolyte (Na, K, Mg) abnormalities, metabolic alkalosis, ototoxicity (high-dose). Monitor UOP, BMP, weight.

Spironolactone / Eplerenone (K-sparing)

• Use: CHF, hyperaldosteronism adjunct.

• Watch: Hyperkalemia, gynecomastia (spironolactone). Monitor K+, renal function.

Mannitol / Hypertonic Saline

• Use: Lower increased ICP (mannitol diuresis, HTS osmolarity).

• Watch: Volume depletion (mannitol), hypernatremia, osmolarity; monitor Na, osmolality, renal function.

I. Vasodilators / Hypertensive Emergency

Nitroprusside (nipride)

• Use: Rapid BP control, hypertensive emergency, severe CHF afterload reduction.

• Watch: Cyanide/thiocyanate toxicity (prolonged/high dose), hypotension, ↑ICP. Monitor BP, lactic acid, thiocyanate in prolonged use.

Nitroglycerin

• Use: Ischemia, pulmonary edema, BP control (coronary vasodilation).

• Watch: Hypotension, headache, tachyphylaxis; avoid in RV infarct. Monitor BP, chest pain relief.

Nicardipine / Clevidipine (IV CCBs)

• Use: Controlled BP lowering (stroke, HTN emergency).

• Watch: Hypotension, reflex tachycardia, heart block (rare). Clevidipine: lipid emulsion → avoid in egg/soy allergy, hypertriglyceridemia.

J. Pulmonary / Respiratory Adjuncts

Albuterol / Ipratropium (nebulizers)

• Use: Bronchospasm, COPD/asthma exacerbations.

• Watch: Tachycardia, tremor, hypokalemia (albuterol). Monitor breath sounds, RR, SpO₂.

Inhaled nitric oxide (iNO) / inhaled epoprostenol

• Use: Refractory hypoxemia with pulmonary hypertension/ARDS; RV failure.

• Watch: Methemoglobinemia (iNO), rebound pulmonary HTN on withdrawal, systemic hypotension. Monitor ABG, methemoglobin if indicated.

K. Renal / Electrolyte Therapies

IV Potassium (KCl)

• Use: Hypokalemia replacement.

• Watch: Never IV push; risk of arrhythmia with rapid infusion. Monitor K+, ECG (if rapid changes).

IV Magnesium sulfate

• Use: Torsades de pointes, eclampsia, asthma adjunct.

• Watch: Hypotension, respiratory depression with overdose; monitor reflexes, Mg level, renal function.

IV Calcium (gluconate / chloride)

• Use: Hyperkalemia, calcium channel blocker overdose, hypocalcemia.

• Watch: Local extravasation injury (CaCl more irritant), arrhythmias. Monitor ECG, electrolytes.

L. Gastrointestinal / Nutrition

Proton-pump inhibitors (pantoprazole) / H2 blockers (famotidine)

• Use: Stress ulcer prophylaxis, GI bleed.

• Watch: C. difficile risk (PPI), hypomagnesemia (PPI long term). Monitor GI bleeding signs.

Metoclopramide / Ondansetron

• Use: Nausea/vomiting.

• Watch: Metoclopramide → extrapyramidal symptoms, tardive dyskinesia; ondansetron → QT prolongation. Monitor neuro status, ECG.

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M. Endocrine & Diabetes (INPATIENT FOCUS)

Key principle: In-hospital, insulin (IV infusion for critical care) is the primary tool. Many outpatient oral agents are held on admission depending on clinical status.

Insulin (IV regular infusion; subcutaneous basal/bolus)

• Use: Hyperglycemia treatment, DKA/HHS management, tight glycemic control in ICU protocols.

• Watch: Hypoglycemia (most common serious adverse event) — monitor bedside glucose hourly for IV infusions; check K+ (insulin drives K+ into cells → hypokalemia risk). Titrate per protocol.

Metformin

• Use: Type 2 diabetes outpatient; sometimes resumed in stable patients.

• Watch / Hold if: AKI, contrast studies with renal insufficiency, severe hypoxia/sepsis/pulmonary disease — risk lactic acidosis. Monitor renal function (eGFR).

Sulfonylureas (glipizide, glyburide)

• Use: Oral glucose lowering (outpatient).

• Watch / Hold if: Risk of prolonged hypoglycemia (esp. glyburide in elderly/renal failure). Monitor glucose, renal/hepatic function.

DPP-4 inhibitors (sitagliptin)

• Use: Mild-moderate hyperglycemia control.

• Watch: Generally well tolerated; adjust for renal function for some agents. Monitor glucose, renal fx.

GLP-1 receptor agonists (exenatide, liraglutide) — usually outpatient/injectable

• Use: Promote insulin secretion/weight loss.

• Watch / Hold if: Nausea, gastroparesis risk; avoid starting acutely inpatient for unstable patients. Monitor GI tolerance, glucose.

SGLT2 inhibitors (empagliflozin, canagliflozin)

• Use: Outpatient diabetes, CV/renal benefits.

• Watch / Hold if: DKA risk (euglycemic DKA), AKI, hypotension; hold perioperatively and in acute illness. Monitor glucose, ketones, renal function, volume status.

TZDs (pioglitazone)

• Use: Insulin sensitizer outpatient.

• Watch / Avoid if: Heart failure (fluid retention), hepatic dysfunction. Monitor weight, edema, LFTs.

Meglitinides (repaglinide) / Alpha-glucosidase inhibitors

• Use: Outpatient prandial control.

• Watch: Hypoglycemia (with missed meals), GI side effects (alpha-glucosidase). Monitor glucose.

In summary for diabetes inpatient:

• Use insulin for most acutely ill patients (IV infusion in ICU, basal-bolus on wards).

• Hold metformin in AKI/sepsis/contrast; hold SGLT2 in acute illness/surgery (risk DKA).

• Watch closely for hypoglycemia — ensure feeding status aligns with insulin regimen. Monitor glucose frequently, K+, renal function.

N. Sepsis Adjuncts

Broad-spectrum antibiotics (see above)

• Use: Source-directed therapy; de-escalate by culture results. Monitor cultures, renal, hepatic, drug levels if needed.

Corticosteroids (hydrocortisone)

• Use: Refractory septic shock (stress-dose).

• Watch: Hyperglycemia, immunosuppression, GI bleed, psychosis. Monitor glucose, electrolytes.

IV Fluids (crystalloids, albumin as needed)

• Use: Resuscitation in sepsis/hypovolemia.

• Watch: Fluid overload (pulmonary edema), electrolyte disturbances. Monitor UOP, CVP/PAWP if available, CXR, weight.

O. Transfusion & Hemostasis

PRBCs / Platelets / FFP / Cryoprecipitate

• Use: Anemia, coagulopathy, active bleeding, thrombocytopenia with bleeding.

• Watch: Transfusion reactions (allergic, hemolytic), TRALI, TACO (volume overload), infective risk, electrolyte shifts (hyperkalemia), hypocalcemia with massive transfusion. Monitor vitals during transfusion, post-transfusion CBC/coags, calcium.

Tranexamic acid (TXA)

• Use: Massive hemorrhage, trauma, postpartum hemorrhage, surgical bleed.

• Watch: Thrombosis risk, seizures at high doses. Monitor bleeding, seizures.

P. Neurologic / ICU Neuro

Mannitol / Hypertonic saline — see above (ICP control)

• Watch: Volume/electrolyte disturbances, renal function, osmolarity, sodium correction rates.

Antiepileptics (levetiracetam, phenytoin, valproate)

• Use: Seizure prophylaxis/treatment.

• Watch: Levetiracetam → agitation; phenytoin → hypotension with bolus, arrhythmia. Monitor levels (phenytoin/valproate), LFTs, CBC.

Q. Other High-Yield / Miscellaneous

Magnesium, phosphate, calcium replacements — see electrolytes section.

• Watch: Overcorrection; cardiac monitoring for rapid shifts.

Vasopressin analogues, desmopressin (DDAVP)

• Use: DI, hemophilia A/vWD periop bleeding.

• Watch: Hyponatremia (DDAVP), ischemia (vasopressin). Monitor Na, urine output.

Insulin-like agents (IV dextrose for hypoglycemia)

• Use: Symptomatic hypoglycemia.

• Watch: Hyperglycemia rebound; start appropriate glucose infusion or oral intake after recovery. Monitor glucose frequently.

R. General Safety & Monitoring Tips (Bedside)

• IV site checks: Vasopressors and irritants → central line preferred; check for extravasation.

• ECG monitoring: For QT-prolonging drugs, antiarrhythmics, electrolytes shifts, and during major drug changes.

• Renal/hepatic dosing: Adjust many meds (antibiotics, inotropes like milrinone, analgesics).

• Glucose monitoring: Hourly with insulin drips until stable; q4–6h with subcutaneous regimens as protocolized.

• Electrolytes: K, Mg, Ca, phosphate should be checked and corrected; insulin can cause hypokalemia.

• Allergy history: Egg/soy (propofol/clevidipine), sulfa (some diuretics), penicillin/β-lactam cross-reactivity.

• Drug interactions: Serotonin syndrome risk (linezolid + SSRI); bleeding risk (anticoagulants + antiplatelets).

• Hold meds pre-procedure: Anticoagulants, certain antihypertensives; follow institutional guidance.