ICU IV Titration & Drip Notes (Nursing)

IV Compatibility (Micromedex in Cerner)

• Use IV compatibility tool to check which drips can run together.

• Rule of thumb:

  • Sedatives → usually compatible with each other.

  • Vasopressors → usually compatible with each other.

  • Not always 100% reliable – verify every time.

• Tip:

  • Print a compatibility chart each shift → include every med patient is receiving.

  • This avoids repeated searching.

• Green checkmark = compatible.

  • Anything else → assume incompatible.

  • Incompatible drugs may crystallize in tubing → clogs line, delays treatment, wastes med & tubing.

  • Life-saving drugs should always be on dedicated lines.

• Example:

  • Dexmedetomidine (Precedex) + Fentanyl → ✅ compatible.

  • Dexmedetomidine + Ketamine → ❌ incompatible (ketamine incompatible with many meds).

Vasopressors – General

• Vasoconstriction → ↑ blood pressure.

• Vasodilation → ↓ blood pressure.

• Analogy:

  • Boba straw (wide lumen) = dilated vessel → easy flow, low pressure.

  • Coffee straw (narrow lumen) = constricted vessel → hard flow, high pressure.

Key Vasopressors

Norepinephrine (Levophed, “Levo”)

• Now first-line in septic shock & hypotension (was last-ditch in past).

• Mechanism: vasoconstrictor.

• Central line preferred (risk of tissue necrosis if extravasation).

• If peripheral: use midline or US-guided IV, monitor site hourly.

• Family teaching: redness, swelling, drainage, color change → report immediately.

• If extravasation: stop infusion, switch to another line, call pharmacy/provider, inject reversal agent if available, document.

• Arrhythmias possible (tachy).

• MAP goal: usually ≥65, but provider-specific.

• Starting dose (institutional): 4 mcg/min → titrate by 2 mcg every 5 min.

• Max: 47 mcg/min (some places higher, but effect plateaus ~45).

• When >10–15 mcg/min → consider adding 2nd pressor (usually vasopressin).

Epinephrine (Epi)

• Later-line pressor (after Levo + Vaso).

• First-line in cardiac arrest (push dose).

• Also used in allergic reactions, refractory shock, bradycardia + hypotension.

• Concentration: 4 mg/250 mL.

• Start: 1 mcg/min → titrate by 1 mcg every 10 min.

• Max: 15 mcg/min.

• Monitor:

  • HR <125.

  • MAP >65.

  • SBP >90.

• Risks: tachyarrhythmias, hyperglycemia.

• You can still give push-dose epi even while drip is running (ACLS dose = 1 mg IV push).

Dopamine (Dopa)

• Old-school pressor, now less common.

• Think cardiac patients.

• Must give fluids first (don’t “dry pump” the heart).

• Concentration: 400 mg/250 mL.

• Dose: 2 mcg/kg/min (weight-based).

• Titration: by 2 mcg/kg/min q10 min.

• Max: 20 mcg/kg/min.

• Effects:

  • Low dose (<10) → ↑ HR/contractility.

  • High dose (>10) → vasoconstriction.

• Complications: tachyarrhythmias, PVCs, VTach.

Phenylephrine (Neo-Synephrine, “Neo”)

• Pure alpha agonist → vasoconstrictor.

• Used in iatrogenic hypotension (e.g., sedation-related).

• Concentration: 100 mg/250 mL.

• Start: 0.5 mcg/kg/min.

• Titrate: by 0.4 mcg/kg/min q5 min.

• Max: ~9 mcg/kg/min.

• Side effect: reflex bradycardia.

• Very potent drug (tiny doses matter).

Vasopressin (Vaso)

• Adjunct pressor (never first-line).

• Often added when Levo >10 mcg/min.

• Concentration: 20 units/100 mL.

• Fixed dose: 0.03 units/min (not titrated in septic shock).

• In GI bleeds: titrated 0.01 units q30 min, max 0.1.

• Caution: very small decimal doses → double-check carefully.

Dobutamine (Dobutrex)

• Inotrope (↑ contractility, some vasodilation).

• Good for cardiogenic shock, heart failure (can offload fluid).

• Concentration: 250 mg/250 mL.

• Start: 1 mcg/kg/min.

• Titrate: by 2.5 mcg/kg/min q5–15 min.

• Max: 40 mcg/kg/min.

• Risks: PVCs, VTach, hypotension, angina.

• Monitor electrolytes if arrhythmias increase.

Antihypertensive Drips (Less Common in ICU)

Nicardipine (Cardene)

• Uses: SAH, aortic dissection, hypertensive crisis.

• Concentration: 40 mg/200 mL (sometimes 20/200).

• Start: 5 mg/hr.

• Titrate: by 2.5 mg/hr q15 min.

• Max: 15 mg/hr.

• Long half-life → slow to recover from hypotension.

Nitroglycerin (Nitro)

• Uses: chest pain, MI, angina, HTN.

• Glass bottle → open vent on tubing.

• Concentration: 50 mg/250 mL.

• Start: 5 mcg/min.

• Titrate: by 5 mcg q5–10 min.

• Max: 400 mcg/min.

• Contraindications: PDE inhibitors (Viagra, Cialis, Levitra) in last 48 hrs.

• Goal: pain <4/10, MAP <110, SBP >90.

• Very short half-life.

Esmolol (Brevibloc)

• Beta blocker drip.

• Uses: aortic dissection, CAD.

• Onset: <1 min.

• Load: 500 mcg/kg over 1 min.

• Start: 50 mcg/kg/min.

• Titrate: by 100 mcg/kg/min q15 min.

• Max: 300 mcg/kg/min.

Labetalol

• Can be push or drip.

• Concentration: 200 mg/200 mL (1:1).

• Start: 0.5 mg/min.

• Titrate: by 1 mg/min q10 min.

• Max: 8 mg/min.

Sedatives & Analgesics (Quick Notes)

• RAS scale used to titrate sedation.

• Dexmedetomidine (Precedex): good for weaning, no respiratory depression.

• Propofol: short half-life, lipid suspension, infection risk, triglyceride check.

• Fentanyl: sedation + pain, weight-based drips.

• Ketamine: analgesic + sedative, risk hallucinations/delirium.

• Midazolam (Versed): benzo, amnesia, ICU delirium risk, slower wake-up.

Nursing Safety Pearls

• Always read the bag label first → concentration errors happen.

• Double-check during handoff/report with incoming nurse.

• Label lines clearly (esp. primary emergency push line).

• Keep lines free of tangles, pumps facing door.

• Document titrations + site assessments.

• If extravasation: stop, switch line, call pharmacy/provider, treat site.