Thursday, August 28, 2025

ICU Medications: Contraindications & Side Effects

1) Vasopressors & Inotropes

Norepinephrine (α1, β1)

  • Avoid/caution: Mesenteric ischemia, severe hypovolemia not yet resuscitated.

  • Watch: Digital/mesenteric ischemia, tachyarrhythmias, ↑afterload → ↓CO in severe LV failure; extravasation necrosis (treat with phentolamine).

Epinephrine (β1/β2/α1)

  • Avoid/caution: Tachyarrhythmias, severe ischemic heart disease, lactic acidosis (may rise).

  • Watch: Tachycardia, arrhythmias, hyperglycemia, lactic acidosis, splanchnic vasoconstriction.

Vasopressin (V1/V2)

  • Avoid/caution: Coronary, mesenteric, or digital ischemia; hyponatremia.

  • Watch: Ischemia (digits/mesentery/coronaries), hyponatremia, skin necrosis if extravasated.

Phenylephrine (pure α1)

  • Avoid/caution: Low-output states, RV failure, severe bradycardia.

  • Watch: Reflex bradycardia, ↓CO, ↓renal/splanchnic flow, limb ischemia, extravasation injury.

Dopamine (dose-dependent DA/β/α)

  • Avoid/caution: Tachyarrhythmias, pheochromocytoma; use has fallen out of favor.

  • Watch: Arrhythmias, ischemia, nausea; higher arrhythmia risk than NE.

Dobutamine (β1>β2)

  • Avoid/caution: HOCM, severe hypotension without pressor support.

  • Watch: Tachyarrhythmias, hypotension (β2 vasodilation), hypokalemia, myocardial ischemia.

Milrinone (PDE-3 inhibitor)

  • Avoid/caution: Severe renal failure (accumulates), hypotension.

  • Watch: Hypotension, tachyarrhythmias, thrombocytopenia (rare).

Isoproterenol (β1/β2)

  • Avoid/caution: Ischemic heart disease, ventricular arrhythmias.

  • Watch: Profound tachycardia, hypotension, ischemia.


2) Antihypertensives / Vasodilators

Nicardipine (IV DHP-CCB)

  • Avoid/caution: Acute decompensated HF, severe AS.

  • Watch: Hypotension, reflex tachycardia, headache.

Clevidipine (IV DHP-CCB, lipid emulsion)

  • Avoid/caution: Egg/soy allergy, defective lipid metabolism, pancreatitis/hypertriglyceridemia.

  • Watch: Hypotension, reflex tachycardia, ↑triglycerides.

Nitroprusside

  • Avoid/caution: Renal/hepatic failure (thiocyanate/cyanide toxicity), ↑ICP.

  • Watch: Hypotension, cyanide/thiocyanate toxicity (AMS, lactic acidosis)—check thiocyanate levels with prolonged/high dose.

Nitroglycerin

  • Avoid/caution: RV MI, severe aortic stenosis, recent PDE-5 inhibitor use.

  • Watch: Headache, hypotension, methemoglobinemia (rare), tachyphylaxis.

Hydralazine

  • Avoid/caution: Severe tachycardia, coronary disease (reflex ischemia).

  • Watch: Hypotension, reflex tachycardia, drug-induced lupus (chronic use).

Esmolol (IV β1-blocker)

  • Avoid/caution: Bradycardia, 2°/3° AV block, decompensated HF, severe bronchospasm.

  • Watch: Bradycardia, hypotension, heart block, bronchospasm (rare).

Labetalol (α/β blocker)

  • Avoid/caution: Bradycardia/heart block, asthma, acute HF.

  • Watch: Hypotension, bronchospasm, bradycardia.


3) Sedation & Analgesia

Propofol

  • Avoid/caution: Hemodynamic instability, egg/soy allergy (emulsion).

  • Watch: Hypotension, apnea, bradycardia; PRIS (metabolic acidosis, rhabdo, renal failure) with high/prolonged doses; hypertriglyceridemia.

Dexmedetomidine

  • Avoid/caution: Severe bradycardia or advanced heart block without pacing, hypotension.

  • Watch: Bradycardia, hypotension, rebound HTN on abrupt stop.

Midazolam (benzodiazepine)

  • Avoid/caution: Severe respiratory depression, myasthenia gravis.

  • Watch: Hypotension, respiratory depression, delirium with prolonged use, accumulation in renal/hepatic failure.

Ketamine

  • Avoid/caution: Uncontrolled HTN, CAD, ↑ICP/↑IOP, schizophrenia.

  • Watch: Hypertension, tachycardia, hypersalivation, emergence reactions; bronchodilation useful in status asthmaticus.

Opioids (Fentanyl, Hydromorphone, Morphine, Remifentanil)

  • Avoid/caution: Severe respiratory depression; morphine caution in renal failure (active metabolites).

  • Watch: Respiratory depression, chest wall rigidity (rapid/high fentanyl), hypotension, bradycardia, ileus, urinary retention, pruritus.

Acetaminophen (IV/PO)

  • Avoid/caution: Severe hepatic disease.

  • Watch: Hepatotoxicity at high dose; track cumulative daily dose.

Ketorolac/NSAIDs

  • Avoid/caution: Renal failure, GI bleed/ulcer, thrombocytopenia, recent cardiac surgery.

  • Watch: AKI, bleeding, GI ulcer, bronchospasm (ASA-sensitive asthma).


4) Neuromuscular Blockers & Reversal

Succinylcholine (depolarizing)

  • Avoid/caution (critical): Malignant hyperthermia, hyperkalemia, burns/crush/spinal cord injury (>24–48h), NM diseases, stroke with paralysis, severe acidosis/sepsis (K+ shift), pseudocholinesterase deficiency.

  • Watch: Hyperkalemia → arrest, MH, bradycardia (esp kids), ↑IOP/ICP, myalgias.

Rocuronium / Vecuronium (non-depolarizing)

  • Avoid/caution: Severe hepatic (roc/vec) or renal (vec) impairment—prolonged effect.

  • Watch: Prolonged paralysis, residual weakness.

Cisatracurium (non-depolarizing, Hofmann elimination)

  • Avoid/caution: Few; preferred in organ failure.

  • Watch: Hypotension (rare), prolonged paralysis if hypothermic/acidotic.

Reversal: Neostigmine + Glycopyrrolate/Atropine

  • Avoid/caution: Mechanical GI/GU obstruction, severe asthma (relative).

  • Watch: Bradycardia, bronchospasm, secretions, abdominal cramps.

Reversal: Sugammadex (for roc/vec)

  • Avoid/caution: Severe renal failure; hormonal contraceptive interaction (backup 7 days).

  • Watch: Bradycardia/asystole (rare), anaphylaxis.


5) Antiarrhythmics & Rate Control

Amiodarone

  • Avoid/caution: Severe bradycardia/heart block; iodine allergy is not absolute but note.

  • Watch (acute): Hypotension (solvent), bradycardia, QT prolongation; (chronic): thyroid dysfunction, hepatotoxicity, pulmonary fibrosis, corneal deposits.

Lidocaine

  • Avoid/caution: Severe hepatic failure, seizure disorder (relative).

  • Watch: CNS toxicity (tinnitus, confusion, seizures), hypotension.

Procainamide

  • Avoid/caution: QT prolongation/torsades risk, SLE.

  • Watch: Hypotension, QRS/QT prolongation, drug-induced lupus.

Adenosine

  • Avoid/caution: Severe asthma/COPD (bronchospasm), high-grade AV block without pacing.

  • Watch: Transient asystole, chest pressure, flushing, bronchospasm.

Magnesium sulfate (for torsades, eclampsia, asthma adjunct)

  • Avoid/caution: Myasthenia gravis, heart block, renal failure (accumulation).

  • Watch: Hypotension, respiratory depression, loss of reflexes, hypermagnesemia.

Metoprolol/Esmolol (β-blockers)

  • Avoid/caution: Bradycardia, AV block, decompensated HF, severe bronchospasm.

  • Watch: Bradycardia, hypotension, bronchospasm.

Diltiazem/Verapamil (non-DHP CCB)

  • Avoid/caution: HFrEF, AV block, bradycardia, WPW with AF.

  • Watch: Hypotension, bradycardia, heart block, edema.

Atropine

  • Avoid/caution: Glaucoma, tachyarrhythmias (relative).

  • Watch: Tachycardia, urinary retention, delirium (elderly).


6) Anticoagulation, Antiplatelets, & Reversal

Unfractionated Heparin (UFH)

  • Avoid/caution: Active bleeding, HIT history, severe thrombocytopenia.

  • Watch: Bleeding, HIT, osteoporosis (long term). Reversal: Protamine.

Enoxaparin (LMWH)

  • Avoid/caution: Renal failure (dose adjust), HIT history.

  • Watch: Bleeding, HIT (less common). Partial protamine reversal.

Bivalirudin / Argatroban (DTIs)

  • Avoid/caution: Active bleeding; argatroban in hepatic failure—dose adjust.

  • Watch: Bleeding; monitor aPTT.

Warfarin

  • Avoid/caution: Pregnancy, active bleeding.

  • Watch: Bleeding, skin necrosis (protein C deficiency). Reversal: Vitamin K, PCC/FFP.

Antiplatelets (Aspirin, Clopidogrel, Ticagrelor)

  • Avoid/caution: Active bleeding, recent ICH; aspirin—true allergy/asthma triad.

  • Watch: Bleeding, thrombocytopenia (rare), dyspnea with ticagrelor.

Thrombolytics (Alteplase/tPA)

  • Avoid/caution: Any active/ recent major bleed, ICH history, uncontrolled HTN, recent surgery.

  • Watch: ICH, systemic bleeding, angioedema.

Tranexamic Acid (TXA)

  • Avoid/caution: Active intravascular clotting, history of thrombosis (relative).

  • Watch: Thrombosis, seizures (high dose), hypotension if pushed fast.

Desmopressin (DDAVP)

  • Avoid/caution: Hyponatremia, significant fluid overload.

  • Watch: Hyponatremia, water retention, headache.


7) Electrolytes & Acid–Base

Potassium (IV/PO)

  • Avoid/caution: Hyperkalemia, severe renal failure without dialysis.

  • Watch: Never IV push; pain/ phlebitis, arrhythmias if infused rapidly; monitor Mg concurrently.

Magnesium sulfate — (see above).

Calcium (Gluconate/Chloride)

  • Avoid/caution: Hypercalcemia, digoxin toxicity (relative—use carefully).

  • Watch: Extravasation necrosis (CaCl), bradyarrhythmias; CaCl is central-line preferred.

Phosphate (KPhos/NaPhos)

  • Avoid/caution: Hyperphosphatemia, hypocalcemia.

  • Watch: Hypocalcemia (tetany), metastatic calcification; adjust for renal failure.

Sodium Bicarbonate

  • Avoid/caution: Volume overload, alkalemia, hypocalcemia.

  • Watch: Hypernatremia, volume expansion, ionized hypocalcemia, CO₂ generation.


8) Endocrine

Insulin (IV infusion/SC)

  • Avoid/caution: Hypoglycemia risk; hold if K⁺ <3.3 in DKA.

  • Watch: Hypoglycemia, hypokalemia, dosing errors—protocolize and hourly glucose checks.

Glucocorticoids (Hydrocortisone, Methylprednisolone, Dexamethasone)

  • Avoid/caution: Uncontrolled fungal infections (classic teaching), GI bleed risk.

  • Watch: Hyperglycemia, immunosuppression, psychosis, myopathy, GI bleed, fluid retention.

Levothyroxine (myxedema coma)

  • Avoid/caution: Untreated adrenal insufficiency (give stress steroids first).

  • Watch: Arrhythmias, ischemia in CAD.


9) Infectious Disease (high-yield ICU antibiotics)

(Not exhaustive—common choices & pitfalls)

Vancomycin

  • Avoid/caution: Renal failure (dose by levels).

  • Watch: Nephrotoxicity, “red man” reaction (infuse slowly), ototoxicity (rare).

Piperacillin–Tazobactam

  • Avoid/caution: Penicillin anaphylaxis.

  • Watch: AKI risk (esp. with vanc), sodium load, diarrhea.

Cefepime

  • Avoid/caution: Severe cephalosporin allergy.

  • Watch: Neurotoxicity/encephalopathy in renal failure (dose adjust).

Meropenem

  • Avoid/caution: Seizure disorder (relative), carbapenem allergy.

  • Watch: Seizures (rare), diarrhea.

Linezolid

  • Avoid/caution: SSRI/SNRI (risk serotonin syndrome), thrombocytopenia, prolonged use.

  • Watch: Thrombocytopenia, optic/peripheral neuropathy (long course), serotonin syndrome.

Daptomycin (not for pneumonia)

  • Avoid/caution: Eosinophilic pneumonia history, statins (myopathy).

  • Watch: CPK elevation, myopathy, eosinophilic pneumonia.

Azithromycin/Levofloxacin

  • Avoid/caution: QT prolongation, myasthenia gravis (fluoroquinolones).

  • Watch: QT prolongation, tendinopathy (levo), dysglycemia (levo), diarrhea.

Acyclovir (IV)

  • Avoid/caution: Renal failure—dose adjust, hydrate.

  • Watch: Crystal nephropathy, neurotoxicity if accumulated.


10) Neurocritical Care

Mannitol

  • Avoid/caution: Hypotension, hypovolemia, renal failure, active intracranial hemorrhage without monitoring.

  • Watch: Osmotic diuresis → hypotension, AKI, hyperosmolality; monitor serum osmolality/Na.

Hypertonic Saline (3%/23.4%)

  • Avoid/caution: Severe hypernatremia, fluid overload/CHF (3% continuous), chronic hyponatremia (avoid rapid correction).

  • Watch: Hypernatremia, osmotic demyelination (if rapid correction), phlebitis (peripheral 3%).

Levetiracetam

  • Avoid/caution: Renal failure—dose adjust.

  • Watch: Somnolence, agitation, mood change.

Valproate

  • Avoid/caution: Hepatic disease, pregnancy.

  • Watch: Hepatotoxicity, hyperammonemia, thrombocytopenia, pancreatitis.

Fosphenytoin/Phenytoin

  • Avoid/caution: Bradycardia, AV block; hypotension with rapid IV.

  • Watch: Hypotension, arrhythmias, purple glove syndrome (phenytoin), CNS toxicity.

Haloperidol/Quetiapine (delirium)

  • Avoid/caution: Prolonged QT, torsades history.

  • Watch: QT prolongation, EPS (halo), sedation, orthostasis.


11) Pulmonary & Sepsis Adjuncts

Albuterol/Ipratropium (nebs)

  • Avoid/caution: Tachyarrhythmias (relative).

  • Watch: Tremor, tachycardia, hypokalemia (albuterol); dry mouth (ipra).

Inhaled Epoprostenol / Nitric Oxide

  • Avoid/caution: Severe bleeding risk (prostacyclin), platelet dysfunction.

  • Watch: Hypotension (systemic spillover), rebound pulmonary HTN when weaned; methemoglobinemia (iNO).

Methylprednisolone (ARDS/asthma/COPD)

  • See glucocorticoids.

Ascorbic Acid/Thiamine/Hydrocortisone (sepsis adjunct—center dependent)

  • Avoid/caution: Oxalate nephropathy risk with high-dose vitamin C.

  • Watch: Hyperglycemia, renal stones (rare).

12) GI & Nausea

Pantoprazole/PPIs

  • Avoid/caution: C. difficile/prior frequent infections (risk consideration).

  • Watch: Hypomagnesemia, C. diff, pneumonia (vented pts), B12 deficiency (long term).

Famotidine (H2 blocker)

  • Avoid/caution: Renal failure—dose adjust.

  • Watch: CNS effects in elderly/renal impairment.

Metoclopramide

  • Avoid/caution: Parkinson’s disease, bowel obstruction, prolonged QT.

  • Watch: Akathisia/EPS, tardive dyskinesia (with chronic use), diarrhea.

Ondansetron

  • Avoid/caution: Prolonged QT/torsades history.

  • Watch: QT prolongation, constipation, headache.

Bowel Regimen (Senna, PEG, Bisacodyl)

  • Avoid/caution: Suspected obstruction.

  • Watch: Diarrhea, electrolyte shifts (with heavy use).

13) Renal/Diuretics

Furosemide/Bumetanide/Torsemide

  • Avoid/caution: Severe hypovolemia, sulfa allergy (rare cross-reactivity).

  • Watch: Hypokalemia, hyponatremia, metabolic alkalosis, ototoxicity (high dose IV), AKI.

Chlorothiazide (IV)

  • Avoid/caution: Sulfa allergy, severe hyponatremia.

  • Watch: Hypo-K/Mg/Na, hyperuricemia.

Acetazolamide

  • Avoid/caution: Sulfa allergy, metabolic acidosis, severe renal/hepatic disease.

  • Watch: Metabolic acidosis, hypokalemia.

14) Transfusion Adjuncts / Hemostatics

Calcium (during massive transfusion) — see electrolytes.
PCC/FFP/Cryo

  • Avoid/caution: DIC without control of source (relative).

  • Watch: Thrombosis (PCC), volume overload (FFP), TRALI/TACO.

Practical Pearls

  • Pressor first steps: Correct hypovolemia, hypoxemia, hypocalcemia, acidosis, and temperature.

  • Lines: Central for vesicants (NE, Epi, CaCl, KCl >10 mEq/100 mL, 23.4% saline).

  • QT prolongers stack: Amio, ondansetron, haloperidol, macrolides, fluoroquinolones—monitor ECG and Mg/K.

  • Renal dosing: Vanc, cefepime, meropenem, levetiracetam, enoxaparin, milrinone.

  • Liver metabolism: Amiodarone, midazolam, fentanyl, lidocaine—dose carefully in hepatic failure.

  • Weaning pitfalls: Rebound HTN (dex, clonidine), rebound PH (iNO/epo), adrenal crisis (long steroid courses).


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