One of the most intimidating skills to learn as a new ICU nurse is how to confidently manage common ICU drips. These are powerful medications delivered directly into the patient’s circulatory system that often elicit immediate effects. While it is the physician who decides when the medication is necessary and orders it, the nurse is the one who physically gives it to the patient, monitors how it impacts the patient, and changes the dosing as needed. It’s quite the responsibility to safely give all of these common ICU drips – but completely doable!
Table of Contents
Guide to Common ICU Drips
In this comprehensive guide, we’ll delve into the trade names, generic names, starting doses, titration guidelines, potential complications, and essential nursing considerations for these vital infusions. All of these medications will be given through an infusion pump, which we discuss more in-depth in this blog post on common ICU equipment.
(Note: While every effort is made to ensure this guide is up to date, this post is for informational purposes only. Your hospital policies and procedures should guide your practice. For more information on our disclaimers, click here. This post was written with the adult patient in mind. Pediatric and neonatal patients would require different dosing and considerations.)
General Tips for Common ICU Drips
Before we get into the meds themselves, here are some general tips on common ICU drips:
- Know what your goal is (a MAP over 65, for example)
- Ensure your bedside monitor’s alarms are set to go off if the patient’s vitals are out of range and require your action
- Label your IV lines close to the insertion site
- If a blood pressure is extremely different from the previous readings, double check it before titrating your drip
- If your blood pressure cuff is set to go off every 5, 10, 15, or more, minutes, glance at it whenever you walk in the room to ensure it has not been accidentally turned off
- If you are using a peripheral IV for short-term vasopressor administration, do not put your blood pressure cuff on that same arm to prevent extravasation
- All of these meds are serious and can cause major complications. We do not want them infusing any longer than necessary. Continually reevaluate the purpose of the med, if we’ve met our goal and if it is clinically appropriate/ordered, look to wean down the drip as the patient response dictates
- Before combining any drips into a single line, ensure you check compatibility
- If the patient is receiving a drip to increase their blood pressure, reevaluate all other meds (in particular the scheduled oral meds), and clarify about any meds that would decrease blood pressure. Many patients take oral blood pressure meds at home and they are often ordered on patients. Don’t blindly give them!
If you’d like to learn about common ICU meds that are not necessarily drips, click here.
Ok, now that we’ve discussed some high-level considerations, let’s talk about common ICU drips.
Dopamine (Intropin)
Generic Name: Dopamine
Starting Dose: 5-10 mcg/kg/min
Titration: Increase by 2-5 mcg/kg/min increments
Complications: Monitor for tachycardia, hypertension, extravasation, and ischemia. Be vigilant for signs of extravasation, which can lead to tissue necrosis.
Nursing Considerations: Assess blood pressure and heart rate frequently. Ensure a large bore IV for administration to prevent extravasation.
This medication is given more often in a cardiac ICU than your standard ICU, but it is still one to know well. Extravasation is a big complication to watch out for, and it is most easily prevented by administering this medication into a central line rather than a peripheral IV.
You may also hear people talking about a “renal dose” of dopamine. When given at a low rate (0.5-3 mcg/kg/min), dopamine causes increased blood flow to the kidneys due to vasodilation without an elevation in the glomerular filtration rate (GFR). Patients suffering from acute tubular necrosis (ATN) should NOT have a “renal dose” of dopamine, as it has been shown to cause harm. It should be noted that a higher dose will cause vasoconstriction. (SOURCE)
Norepinephrine (Levophed)
Generic Name: Norepinephrine
Starting Dose: 0.01-0.1 mcg/kg/min
Titration: Increase by 0.01-0.1 mcg/kg/min increments
Complications: Watch for hypertension, tachycardia, extravasation, and decreased peripheral perfusion.
Nursing Considerations: Monitor blood pressure, heart rate, and peripheral perfusion closely. Administer through a central line to minimize extravasation risk.
You may hear this referred to as “Levo” on the nursing unit. It is the first-line treatment for hypotension that is unresponsive to fluid resuscitation. It is a peripheral vascular vasoconstrictor – and it’s powerful! You will likely see this given for hypotension related to sepsis that’s not responding to fluids.
Its half-life is very short, only 2.5 minutes, so if you have a patient on it and that is the only thing keeping their blood pressure up, make sure there are no interruptions to that drip! This means paying attention to when the bag is running low, replacing it promptly, and keeping your IV pump charged.
As an ICU nurse, you will likely give this medication every single shift – it is the most common ICU drip. Here’s a great free article that explains all of the intricacies of this medication. I highly recommend learning what you can about it, and paying close attention at the bedside when your preceptors, or more experienced colleagues are discussing it.
Epinephrine (Adrenaline)
Generic Name: Epinephrine
Starting Dose: 0.01-0.1 mcg/kg/min
Titration: Increase by 0.01-0.1 mcg/kg/min increments
Complications: Be alert for tachycardia, hypertension, arrhythmias, and extravasation.
Nursing Considerations: Continuous ECG monitoring is essential. Administer through a central line whenever possible.
This is often referred to as “epi”. As an ICU nurse, you’ll give this most often in a code situation. The dosing during a code are intermittent IV push doses, rather than an actual drip. If a patient does not already have a central line in place prior to the code, it is appropriate to give epi in a peripheral IV. If the patient stabilizes but will require an epi drip, then you will want to get a central line. The intermittent emergency dosing is often non-weight based, while the drip is often given based upon the patient’s weight in kilograms.
Watch out for an increased lactate level and renal issues. This med causes vasoconstriction to the kidneys. Likely, if your patient needs an epi drip, you’re monitoring BUN/Creatinine labs at least daily. Pay attention to urine output!
Vasopressin
Generic Name: Vasopressin
Starting Dose: 0.01-0.04 units/min
Titration: Adjust to achieve target blood pressure, but avoid exceeding 0.04 units/min
Complications: Monitor for hypertension, decreased cardiac output, and hyponatremia.
Nursing Considerations: Frequent blood pressure monitoring is crucial. Watch for signs of fluid overload or hyponatremia.
This medication is often given to patients who are on increasing doses of norepinephrine that are unresponsive. It can help actually reduce the amount of norepinephrine needed. Adding vasopressin is a common aspect of a sepsis protocol.
You will likely see this as a set infusion rate, rather than a medication that you titrate when given for sepsis. It is currently recommended to infuse continuously at 0.03 units/min when added to norepinephrine, with an acceptable range of 0.01 – 0.04 units/min, but not to exceed 0.04 units/min.
Major clinical tip! If you are about to discontinue the vasopressin on a patient who is also on norepinephrine, it is now recommended to taper it slowly off, as clinically significant hypotension can occur. UpToDate currently recommends slowly tapering by 0.01 units/min every 30-60 minutes and watching MAP closely. (If they’re on 0.03 units/min, it won’t take more than three hours, at most, if they respond well.)
Remember: Always follow your institution’s guidelines for dosing.
Insulin
Generic Name: Regular Insulin
Starting Dose: 2-4 units/hr (variable based on blood glucose), may require loading dose depending on the patient’s diagnosis and needs
Titration: Adjust based on blood glucose levels, following a prescribed protocol.
Complications: Hypoglycemia is a significant risk. Monitor blood glucose closely.
Nursing Considerations: Check blood glucose levels at regular intervals. Administer through a dedicated line to prevent mixing with other infusions.
While this is a common ICU drip, it is based on a blood glucose reading rather than vital sign changes. The frequency of the blood sugar checks depends on the stability of their levels. You might need to check it as often as every 15 minutes (when extremely high or low), all the way to every 4-6 hours.
To see a very basic example of an ICU insulin infusion protocol, click here. This example is from 2008, but you can view the way it is structured. There are different algorithms, which are selected by the physician. These vary in how aggressive they would like to be in managing glucose, as patients can have very different goals and needs.
Any patient receiving insulin should have hypoglycemia order set on their chart. This enables you to address and treat any episodes of hypoglycemia autonomously. To see a sample hypoglycemia protocol, click here. Note, this protocol is over a decade old and merely an example.
For critically ill patients, the current recommendation is to maintain a blood glucose level of 140-180 mg/dL. There is quite a bit of variation, and there may be rationale for a more stringent approach rather than something more moderate. Your ICU will likely have an established protocol.
Neosynephrine (Phenylephrine)
Generic Name: Phenylephrine
Starting Dose: 20-100 mcg/min
Titration: Increase by 20-50 mcg/min increments as needed
Complications: Be vigilant for hypertension, reflex bradycardia, and decreased cardiac output.
Nursing Considerations: Monitor blood pressure and heart rate closely. Administer through a central line to reduce the risk of extravasation.
This med is a treatment for hypotension, but it’s not first-line. (Remember which one is? Levophed!) It gets utilized most in the operating room for blood pressure management during general anesthesia. Severe bradycardia is a major complication to watch out for. This can reduce cardiac output, which is the exact opposite of what we want with a hypotensive patient. Because of this, if your patient has a history of heart failure, cardiogenic shock, severe coronary artery disease, heart block, or myocardial disease, it likely will not be used.
I personally saw this med used much more frequently in the neuro ICU rather than the cardiovascular ICU, as the patients in a neuro ICU are there for a brain issue and not a heart issue.
Fun fact: It is also available over the counter to treat nasal decongestion!
Propofol (Diprivan)
Generic Name: Propofol
Starting Dose: 5-10 mcg/kg/min for sedation
Titration: Adjust to achieve desired level of sedation, typically in 5-10 mcg/kg/min increments
Complications: Watch for hypotension, respiratory depression, delirium, and hypertriglyceridemia.
Nursing Considerations: Continuously monitor blood pressure, respiratory rate, and sedation level. Ensure lipid levels are monitored regularly in long-term use. Patients must be on a ventilator. This does not provide pain control.
This med has a very high lipid content and, therefore, requires more frequent IV tubing changes. Depending on the manufacturer, it could be every 12-24 hours. Also, if your patient is receiving this for a long period of time and getting enteral or parenteral feedings, you’ll need to work with your dietician to prevent inappropriate caloric intake.
If you need to pause the infusion for any amount of time, ensure you flush the line. This medication is much more likely to clot the line than others. You should titrate to clinical response. You likely need to chart a sedation score (for example, a RASS score) to ensure they are not under-sedated or over-sedated.
Last, sedation is not sleep. Just because a patient appears to be resting comfortably does not mean they are. The patient could be caught in a terrible nightmare that we’re keeping them in. Propofol prevents REM sleep, so we are inducing sleep deprivation with this med. Like all of the other meds, this needs to be discontinued as soon as it is no longer clinically appropriate.
Common ICU Drips: Final Thoughts
These meds can be intimidating but learning about the most common ICU drips is absolutely doable. I have a free mini-course that digs even deeper into this important topic that comes with PDF downloads and cheatsheets. Click here to enroll for free.
At first, you’ll be nervous but soon you’ll be an absolute pro with these medications as you get more comfortable with them. They will become part of your everyday routine as an ICU nurse, just like so many other brand-new skills! For a full ICU nurse master list, click here.
Remember: The possibility for harm in the absence of diligence is profound in the ICU. Get into a solid safety routine when administering drips and always double check drips that are infusing on a patient when you take over for another nurse. As much as I love my nursing colleagues, I always check the infusion site, rate, weight, IV pump, bag, and tubing every time.
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References
Clinical tip: Most of this article was referenced with UpToDate, which requires a subscription. If you work at a hospital, you likely have access to this (expensive) service at no additional cost on the intranet at work. Therefore, if you’d like to read any of these full articles that are from UpToDate, simply click on the link to UpToDate, and search the topic.
- https://www.uptodate.com/contents/phenylephrine-systemic-drug-information
- https://www.uptodate.com/contents/glycemic-control-in-critically-ill-adult-and-pediatric-patients
- https://www.uptodate.com/contents/vasopressin-drug-information
- https://www.uptodate.com/contents/renal-actions-of-dopamine
- https://www.uptodate.com/contents/evaluation-and-management-of-suspected-sepsis-and-septic-shock-in-adults
- https://pubmed.ncbi.nlm.nih.gov/22078916/
- https://pubmed.ncbi.nlm.nih.gov/11373423/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9967703/
- https://www.ncbi.nlm.nih.gov/books/NBK537259/
- https://www.drugs.com/medical-answers/what-do-you-mean-by-the-half-life-of-a-drug-458946/
- https://en.wikipedia.org/wiki/Richmond_Agitation-Sedation_Scale
- https://my.clevelandclinic.org/health/articles/24925-extravasation
- https://www.dshs.texas.gov/sites/default/files/txdiabetes/toolkit/Ins_ICUInsulinOrders.pdf
- https://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/adult-hypoglycemia-management-protocol.pdf
- https://www.researchgate.net/figure/Identifying-IV-Infusions-Preprinted-Labels-Abbreviation-IV-intravenous_fig5_262188586
- https://www.wolterskluwer.com/en/solutions/lexicomp/resources/facts-comparisons-user-academy/trissels-iv-compatibility-databases
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