Icu Medications

Drug

Class

Dose per kg average

Pressors, Inotropcs, and Chronotropes

Phenylephrine

ai

10-300 pg/min

Norepinephrine

ai>ßi

1-40 pg/min

Vasopressin

V,

0.01-0.1 U/min (usually 0.04)

Epinephrine

«i.aj.ßi.ßj

2-20 pg/min

Isoproterenol

0.1-10 pg/min

Dopamine

ß.D a.ß.D

0.5-2 pg/kg/min 2-10 pg/kg/min >10 pg/kg/min

50-200 pg/min 200-500 pg/min 500-1000 pg/min

Dobutamine

ßi>ßi

2-20 pg/kg/min

50-1000 pg/min

Milrinone

PDE

50 pg/kg over 10 min then 0.375-0.75 pg/kg/min

3-4 mg over 10 min then 20-50 pg/min

Inamrinone

PDE

0.75 mg/kg over 3 min then 5-15 pg/kg/min

40-50 mg over 3 min then 250-900 pg/min

Vasodilators

Nitroglycerin

NO

10-1000 pg/min

Nitroprusside

NO

0.1-10 pg/kg/min

5-800 pg/min

Nesiritide

BNP

2 pg/kg IVB then 0.01 pg/kg/min

Labetalol

ai.ßi.and ßi blocker

20 mg over 2 min then 20-80 mg q10min or 10-120 mg/h

Fenoldopam

D

0.1-1.6 pg/kg/min

10-120 pg/min

Epoprostenol

vasodilator

2-20 ng/kg/min

Enalaprilat

ACE

0.625-2.5 mg over 5 min then 0.625-5 mg q6h

Hydralazine

vasodilator

5-20 mg q20-30min

Antiarrhythmics

Amiodarone

K et al.

150 mg over 10 min, then

(Class III)

1 mg/min x 6h. then 0.5 mg/min x 18h

Lidocaine

Na channel (Class IB)

1-1.5 mg/kg then 1-4 mg/min

100 mg then 1-4 mg/min

Procainamide

Na channel (Class IA)

17 mg/kg over 60 min then 1-4 mg/min

1 g over 60 min then 1-4 mg/min

Ibutilide

K channel (Class III)

1 mg over 10 min. may repeat < 1

Propranolol

ß blocker

0.5-1 mg q5min then 1-10 mg/h

Esmolol

ßi -ß> blocker

500 ng/kg then 25-300 jig/kg/min

20-40 mg over 1 min then 2-20 mg/min

Verapamil

CCB

2.5-5 mg over 1-2 min repeat 5-10 mg in 15-30 min prn 5-20 mg/h

Diltiazem

CCB

0.25 mg/kg over 2 min reload 0.35 mg/kg x 1 prn then 5-15 mg/h

20 mg over 2 min reload 25 mg x 1 prn then 5-15 mg/h

Adenosine

purinergic

6 mg rapid push if no response: 12 mg — 12-18 mg

Drug

Class

Dose

per kg

average

Sedation

Morphine

opioid

1-unlimited mg/h

Fentanyl

opioid

50-100 ng then 50-unlimited fig/h

Thiopental

barbiturate

3-5 mg/kg over 2 min

200-400 mg over 2 min

Etomidate

anestheoc

0.2-0.5 mg/kg

100-300 mg

Propofol

anesthetic

1-3 mg/kg then 0.3-5 mg/kg/h

50-200 mg then 20-400 mg/h

Diazepam

BDZ

1-5 mg q1-2h then q6h prn

Midazolam

BDZ

0.5-2 mg qSmin prn or 0.5-4 mg then 1-10 mg/h

Ketamine

anestheoc

1-2 mg/kg

60-150 mg

Haloperidol

antipsychotic

2-5 mg q20-30min

Naloxone

opioid antag.

0.4-2 mg q2-3min to total of 10 mg

Flumazenil

BDZ antag.

0.2 mg over 30 sec then 0.3 mg over 30 sec if still lethargic may repeat 0.5 mg over 30 sec to total of 3 mg

Paralysis

Succinylcholine

depolar. paralytic

0.6-1.1 mg/kg

70-100 mg

Tubocurare

nACh

10 mg then 6-20 mg/h

Pancuronium

nACh

0.08 mg/kg

2-4 mg q30-90'

Vecuronium

nACh

0.08 mg/kg then 0.05-0.1 mg/kg/h

5-10 mg over 1-3 min then 2-8 mg/h

Cisatracurium

nACh

5-10 jig/kg/min

Miscellaneous

Aminophylline

PDE

5.5 mg/kg over 20 min then 0.5-1 mg/kg/h

250-500 mg then 10-80 mg/h

Insulin

10 U then 0.1 U/kg/h

Glucagon

5-10 mg then 1-5 mg/h

Octreotide

somatostatin analog

50 fxg then 50 jig/h

Phenytoin

antiepileptic

20 mg/kg at 50 mg/min

1-1.5 g over 20-30 min

Fosphenytoin

antiepileptic

20 mg/kg at 150 mg/min

1-1.5 g over 10 min

Phenobarbital

barbiturate

20 mg/kg at 50-75 mg/min

1-1.5 g over 20 min

Mannitol

osmole

1.5-2 g/kg over 30-60 min repeat q6-12h to keep osm 310-320

ANTIBIOTICS

The following tables of spectra of activity for different antibiotics are generalizations. Sensitivity data at your own institution should be used to guide therapy.

Penicillins

Generation

Properties

Spectrum

Natural

Some GPC. GPR. GNC, most anaerobes (except Bacteroides)

Group A streptococci Enterococci. Listeria Pasteurella Actinomyces, Syphilis

Anti-Staph

Active vs. PCNase-producing Staph Little activity vs. Gram ©

Staphylococci (except MRSA) Streptococci

Amino

Penetrates porin channel of Gram 3 Not stable against PCNases

£ co/r, Proteus. H. influenzae Salmonella, Shigella Enterococci, Listeria

Extended

Penetrates porin channel of Gram 0 More resistant to PCNases

Most GNR incl. Enterobacter, Pseudomonas. Serratia

Carbapenem

Resistant to most (J-lactamases

Most gram • and G bacteria incl. anaerobes (except MRSA andVRE)

Monobactams

Active vs. Gram but not Gram *

Gram Q bacterial infxn in Pt w/ PCN or Ceph allergy

ß-lact. Inhib.

Inhib. plasma-mediated (J-lactamases

Adds Soph. B. fragiUs and some GNR (H. influenzae. M. catarrhohs, some KJesiella)

Cephalosporins

Resistant to most ß-loaamoses. No acbvity vs. MRSA or enterococci.

Gen.

Spectrum

Indications

First

Most GPC (incl. Staph & Strep) Some GNR (incl. £ cod, Proteus, Klebsiella)

Used for surgical prophylaxis & skin infxns

Second

i activity vs. GPC. * vs. GNR. 2 subgroups: Respiratory, t activity vs. H. influenzae & M. catarrhohs

GI/GU: t activity vs. 6. frogdis

PNA/COPD flare Abdominal infxns

Third

Broad activity vs. GNR and some anaerobes Ceftazidime active vs. Pseudomonas

PN A sepsis, meningitis

Fourth

T resistance to ß-lactamases (incl. of Staph and Enterobacter)

Similar to 3rd gen. MonoRx for nonlocalizing febrile neutropenia

Other Antibiotics

Antibiotic Vancomycin

Spectrum

Gram • bacteria incl. MRSA. PCNase-producing pneumococci and enterococci (except VRE)

Linezolid Daptomycin Quinopristin/ Dalfopristin Quinolones

GPC incl. MRSA & VRE

Enteric GNR & atypicals. 3rd & 4th gen. f activity vs. Gram ©.

Aminoglycosides

GNR. Synergy w/ cell-wall active abx (ß-lactam. vanco) vs. GPC. 1 activity in low pH (eg. abscess). No activity vs. anaerobes.

Macrolides

GPC. some respiratory Gram ©. atypicals

TMP-SMZ

Some enteric GNR. PCP. Nocardia. Toxoplasma, most community-acquired MRSA

Clindamycin

Gram © (except enterococci) & anaerobes (incL ß frogHis)

Metronidazole

Anaerobes (incL ß frogihs)

Doxycycline

Rickettsia, Ehrlichia, Chlamydia. Mycoplasma, Nocardia, Lyme

Penicillins

Antibiotic

m___Dose in renal failure (by GFR)

>50

10-50

<10

Natural penicillins

Penicillin G

0.4-4 MU IM/IV q4h NC

NC

1-2 MUq4h

Penicillin V

250-500 mg PO q6h NC

NC

NC

Antt-staphylococcal

Dicloxacillin

250-SOO mg PO q6h NC

NC

NC

Nafcillin

1-2 g IM/IV q4h NC

NC

NC

Oxacillin

1-2 g IM/IV q4h NC

NC

NC

Amlnopenicilllns

Amoxicillin

250-500 mg PO q8h NC

250-500 mg q8-12h

250 mg ql 2h

Amox-dav

250-500 mg PO q8h NC

250-500 mg q8-12h

250 mgq12h

Ampicillin

1-2 g IM/IV q4h NC

1-2 g q8h

1-2 gq12h

Amp-sulbact

1.5-3 g IM/IV q6h NC

1.5-3 g q12h

1.5-3 g q24h

Extended-spectrum penicillins

Piperacillin

2-4 g IM/IV q4-6h NC

2-4 g q8h

2-4 g q12h

Pip-tazo

3.375 g IV q6h NC

2.25 g q6h

2.25 g q8h

Ticarciliin

2-4 g IM/IV q4h NC

2-3 g q6h

2gq12h

Ticar-clav

3.1 g IV q4h NC

3 1gq6h

2 g q12h

Other ß-tactoms

Aztreonam

1-2 g IM/IV q8h NC

1gq8h

0.5 g q8h

Ertapenem

1 g IV/IM q24h NC

0.5 g q24h (if CrCI - 30)

Imipenem

250-500 mg IV q6h NC

250-500 mg q8-12h

250-500 mg q12h

Meropenem

1 g IV q8h NC

0.5-1 g IV q12h

0.5 g IV q24h

Macroltdes

Antibiotic

Normal dose

Dose in renal failure (by GFR)

>50

10-50

<10

Azithromycin

500 mg IV qd 500 mg PO on d 1. then 250 mg PO qd

NC

NC

NC

Clarithromycin

250-500 mg PO bid

U

!i

! i

Erythromycin

0.5-1 g IV q6h 250-500 mg PO qid

NC

NC

250-500 mg IV or 250 mg PO q6h

Telithromycin*

800 mg PO qd

NC

600 mg qd (if CrCI .-30)

'Ketolide (ketone derivative of macrolide nucleus)

Tetracyclines

Antibiotic

Normal dose

Dose in renal failure (by GFR)

>50

10-50 <10

Doxycycline

100 mg PO/IV q12-24h

NC

NC NC

Tigecycline

100 mg IV y 1 then 50 mg q12h

NC

NC NC

Cephalosporins

Antibiotic

Normal dose

Dose in renal failure (by GFR)

>50

10-50

<10

Ist generation

Cefadroxil

0.5-1 gPOq12h

NC

0.5 g q 12-24h

0.5 g q36h

Cefazolin

1 g IM/IV q8h

NC

1gq12h

1 g q24h

Cephalexin

250-500 mg PO q6h

NC

NC

NC

2nd generation

Cefaclor

250-500 mg PO q8h

NC

NC

NC

Cefotetan

1-2 g IM/IV q12h

NC

1-2 g q24h

1 g q24h

Cefoxitin

1-2 g IM/IV q4h

1-2 g q6h

1-2gq8h

1 g q12h

Cefprozil

250-500 mg PO q12-24h

NC

NC

250mgq12h

Cefuroxime

750-1500 mg IM/IV q6h

NC

750-1500 mg q8h

750 mg q24h

Loracarbef

200-400 mg PO q12h

NC

200 mg q12h

200 mg q3-5d

3rd generation

Cefdinir

600 mg PO qd

NC

NC

300 mg qd

Cefditoren

200-400 mg PO bid

NC

200 mg bid

200 mg qd

Cefixime

400 mg PO q24h

NC

300 mg q24h

200 mg q24h

Cefoperazone

1-3 g IV q8h

NC

NC

NC

Cefotaxime

1-2 g IM/IV q6h

NC

NC

1-2 g q12h

Cefpodoxime

100-400 mg PO q12h

NC

NC

400 mg q24h

Ceftazidime

1-2 g IV q8h

NC

1-2 g q 12h

1 g q24h

Ceftibuten

400 mg PO qd

NC

200 mg qd

100 mg qd

Ceftizoxime

1-2 g IV q6h

NC

1 g q!2h

0.5 g q12h

Ceftriaxone

1-2 g IM/IV q12-24h

NC

NC

NC

4th generation

Cefepime

1-2 g IM/IV q12h

NC

1-2 g q 16-24h

1-2 g q24-48h

Fluoroquinolones

Antibiotic

Normal dose

Dose in renal failure (by GFR)

50

10-50

<10

1st generation

Nalidixic acid

1 g PO qid

n/a

n/a

n/a

2nd generation

Ciprofloxacin

500-750 mg PO q12h 200-400 mg IV q12h

NC

250-500 mg q12h

250-500 mg q24h

Lomefloxacin

400 mg PO qd

NC

200-400 mg qd

200 mg qd

Norfloxacin

400 mg PO q12h

NC

400 mg q12-24h

400 mg q24h

Ofloxacin

200-400 mg PO/IV q12h

NC

400 mg q24h

200 mg q24h

3rd generation

Levofloxacin

250-500 mg PO/IV q24h

NC

250 mg q24h

250 mg q48h

4th generation

Gatifloxacin

400 mg PO/IV qd

NC

200 mg qd

200 mg qd

Gemifloxacin

320 mg PO qd

NC

160 mgqd

Moxifloxacin

400 mg PO qd

NC

NC

NC

Aminoglycosides

Antibiotic

Normal dose

Dose in renal failure (by GFR)

■50 10-50 <10

Gentamicin Tobramycin

1-1.7 mg/kg q8h

60-90% 30-70% 20-30% q8-12h q12-18h q24-48h or 1-1.7 mg/kg q(8 • serum Cr)h

Amikacin

5 mg/kg q8h

60-90% 30-70% 20-30% q8-12h q 12-18h q24-48h or - 5 mg/kg q(8 :■ serum Cr)h

Other Antibiotics

Antibiotic

Normal dose

Dose in renal failure (by GFR)

•50

10-50

<10

Chloramphenicol

0.5-1 g IV/PO q6h

NC

NC

NC

Clindamycin

600 mg IV q8h 150-300 mg PO qid

NC

NC

NC

Daptomycin

4 mg/kg IV q24h

NC

4 mg/kg q48h (if CrCI <30)

Linezolid

400-600 mg IV/PO q12h

NC

NC

NC

Metronidazole

1000 mg load then 500 mg IV/PO q6h

NC

NC

NC

Nitrofurantoin

50-100 mg PO qid

NC

avoid

avoid

Quinopristin/ Dalfopristin

7.5 mg/kg IV q8-12h

NC

NC

NC

TMP-SMX»

2-5 mg TMP/kg PO/IV q6h

NC

2-5 mg TMP/kg q12h

avoid

Vancomycin

1 g IV q12h

NC

1 g q24-72h ✓ trough (goal 5-10. î <15 for some infcns) adjust dose & interval

('single strength table = 1 ampule = 80 mg of TMP - 400 mg SMX)

('single strength table = 1 ampule = 80 mg of TMP - 400 mg SMX)

FORMULAE AND QUICK REFERENCE

Cardiology

Hemodynamic parameters

Normal value

SBP + (DBP x 2) Mean arterial pressure (MAP) ---—

70-100 mmHg

Heart rate (HR)

60-100 bpm

Right atrial pressure (RA)

s6 mmHg

Right ventricular (RV)

systolic 15-30 mmHg diastolic 1-8 mmHg

Pulmonary artery (PA)

systolic 15-30 mmHg mean 9-18 mmHg diastolic 6-12 mmHg

Pulmonary capillary wedge pressure (PCWP)

s12 mmHg

Cardiac output (CO)

4-8 L/min

Cardiac index (CI) —-BSA

2.6-4.2 L/min/m*

Stroke volume (SV) = —— HR

60-120 ml/contraction

Stroke volume index (SVI) = —

40-50 ml/contraction/mJ

Systemic vascular resistance (SVR) MAP - mean RA

CO x8°

800-1200 dynes x sec/cms

Pulmonary vascular resistance (PVR) mean PA - mean PCWP _ CO x8°

120-250 dynes x sec/cm5

("Rule of 6i" for PA catheter-mcaiured pressures: RA r.6, RV -.30/6, PA -,30/12. WP s 12) (1 mmHg = 1.36 cm water or Wood)

("Rule of 6i" for PA catheter-mcaiured pressures: RA r.6, RV -.30/6, PA -,30/12. WP s 12) (1 mmHg = 1.36 cm water or Wood)

Fick cardiac output

Oxygen consumption (L/min) CO (L/min) x arteriovenous (AV) oxygen difference CO oxygen consumption / AV oxygen difference

Oxygen consumption must be measured (can estimate w/ 125 ml/min/m2, but inaccurate) AV oxygen difference Hb (g/dl) x 10 (dl/L) x 1.36 (ml 02/g of Hb) x (S,02-Sv02) SjOj is measured in any arterial sample (usually 93-98%)

S,Oj (mixed venous Oj) is measured in RA. RV. or PA (assuming no shunt) (normal 75%) Oxygen consumption

Cardiac output (L/min) :

Shunts

Hb (g/dl) x 13.6 x (S.O, - S,Oi) Oxygen consumption

Pulm. vein O; sat - Pulm. artery Oj sat Oxygen consumption

(MVO; drawn proximal to potential L -» R shunt) (if only I -. R and no R — I shunt)

Valve area

Gorlin equation: Valve area = -— (constant = 1 for AS. 0.85 for MS)

44.3 x constant X VAP co

Coronary artery anatomy

Figure 10-5 Coronary arteries

(From Grossman WG. Cardiac Catheterization and Angiography. 4th ed. Philadelphia: Lea & Febiger. 1991. with permission.)

Pulmonary

Dead space - lung units that are ventilated but not perfused Intrapulmonary shunt - lung units that are perfused but not ventilated

Alveolar gas equation: P*Oj F,0, x (760 47) R (where R - 0.8)

p.co2

I A-a gradient PaOj P,Oi [normal A-a gradient 4 • (age/4)] Minute ventilation (VE) tidal volume (VT) ■ respiratory rate (RR) (normal 4-6 L/min) Tidal volume (Vr) = alveolar space (VA) + dead space (Vo)

! Fraction of tidal volume that is dead space

C02 Production P.COi = k = x - ( — = k x alveolar ventilation

RIGHT CORONARY ARTERY

LAO RAO

LEFT CORONARY ARTERY

RIGHT CORONARY ARTERY

LAO RAO

1 Conus artery

2. SA node artery

3. Acute marginal branches

4. Posterior descending artery (PDA)

5. AV node artery

6. Posterior left ventricular artery (PLV)

1 Left anterior descending artery (LAD)

2 Ramus medianus artery

3. Diagonal branches

4. Septal branches

5 Left circumflex artery (LCx)

6. Lelt atrial circumflex artery

7. Obtuse marginal branches

Nephrology

Anion gap (AG) - Na (CI - HCOj) (normal = [alb] x 2.5; typically 12:2 mEq) Delta-delta (AA) = [A AG (ie. rale. AG - expected) / A HCOj (ie. 24 - measured HCO,)]

/glc\ (BUN\ / EtOH \ Calculated osmoles - (2 x Na) + J + j + 1 ■J

Osmolal gap (OG) = measured osmoles - calculated osmoles (normal • 10)

Estimated creatinine clearance

Corrected Na in hyperglycemia estimate In all Pts: corrected Na measured Na +

however. A in Na depends on gle {Am J Med 1999.1« 399) A is 1.6 mEq per each 100 mg/dl 1 in gle ranging from 100-440 A is 4 mEq per each IOO mg/dl 1 in gle beyond 440

Total body water (TBW) 0.60 x IBW ( x 0.85 if female and x 0.85 if elderly)

Free H,0 deficit TBW

Trans-tubuiar potassium gradient (TTKG) - UK

Hematology

Heparin for Thromboembolism

80 U/kg bolus 18 U/kg/h

PTT

Adjustment

•40

bolus 5000 U. I rate 300 U/h

40-49

bolus 3000 U, t rate 200 U/h

50-59

t rate 100 U/h

60-85

no A

86-95

1 rate 100 U/h

96-120

hold 30 min.. rate 150 U/h

120

hold 60 min. 1 rate 200 U/h

(Ort 2001:103 2994)

(Ort 2001:103 2994)

Heparin for ACS

STEMI w/ fibrinolysis

60 U/kg bolus (max 4000 U) 12 U/kg/h (max 1000 U/h) UA/NSTEMI 60-75 U/kg bolus (max 5000 U) 12-15 U/kg/h (max 1000 U/h)

<40

Adjustment bolus 3000 U.! rate 100 U/h

40-49

1 rate 50 U/h

50-70

no A

71-85

1 rate 50 U/h

86-100

hold 30 min.; rate 100 U/h

101-150

hold 60 min. 1 rate 150 U/h

>150

hold 60 min. 1 rate 300 U/h

(ACC/AHA 2004 Gukkl.11« lor STEMI)

(ACC/AHA 2004 Gukkl.11« lor STEMI)

/ PTT q6h after every change (half-life of heparin is 90 min) / PTT qd or bid once PTT is therapeutic y CBC qd (to ensure Hct and pit counts are stable)

Warfarin Loading Nomogram

Day

INR

<1.5 1.5-1.9

2-2.5

2.6-3

>3

1-3

5 mg (7.5 mg if > 80 kg)

2.5-5 mg

0-2.5 mg

0 mg

4-5

10 mg 5-10 mg

0-5

mg

0-2.5 mg

6

Dose based on requirements over preceding 5 days

(Annoft 1997; 126:13 3; Archives 1999;1S946) Warfarin-heparin overlap therapy

• Indications: when failure to anticoagulate carries T risk of morbidity or mortality

(eg. DVT/PE, intracardiac thrombus)

• Rationale: (1) Half-life of factor VII (3-6 h) is shorter than half-Ufe of factor II (60-72 h);

.. warfarin can elevate PT before achieving a true antithrombotic stale (2) Protein C also has half-life less than that of factor II; .. theoretical concern of hypercoagulable state before antithrombotic state Method: (1) Therapeutic PTT is achieved using heparin

(2) Warfarin therapy is initiated

(3) Heparin continued until INR therapeutic for s 2 d and s 4-5 d of warfarin (roughly corresponds to - 2 half-lives of factor II or a reduction to - 25%)

Other

Ideal body weight (IBW) [50 kg (men) or 45.5 kg (women)] + 2.3 kg/inch over 5 feet

V 3600

present

absent

Test

® (true®)

(false 8)

9 (false 3)

(true 9)

all patients a + b + c + d true positives a true negatives d

all diseased a + c all healthy b + d true positives a

© Predictive value

© Predictive value | Accuracy all positives a + b true negatives <j all negatives c + d true positives + true negatives a + d

© Likelihood ratio

© Likelihood ratio all patients a + b + c true positive rate Se false positive rate 1 - Sp false negative rate 1 - Se true negative rate Sp probability odds

1 - probability odds + 1

Posttest odds = pretest odds x LR

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