Adult dosing for study purposes. Verify every dose against your institution's references and the package insert before clinical use. Weight-based doses use actual body weight unless noted; adjust for renal/hepatic function.
Vasopressors & inotropes
| Drug | Dose | Pearls |
|---|---|---|
| Norepinephrine | 0.01–0.5 mcg/kg/min (start 0.05–0.1); doses >1 mcg/kg/min used in refractory shock | First-line in septic and most undifferentiated shock. α₁ ≫ β₁. Add vasopressin at ~0.25–0.5 mcg/kg/min. Initial MAP goal 65 (SSC 2026: 60–65 mmHg in patients ≥65 y). |
| Vasopressin | 0.03 units/min fixed (range 0.01–0.04) | Catecholamine-sparing second agent; not titrated. V₁ receptor; no β effect. Watch for digital/mesenteric ischemia. |
| Epinephrine | Infusion 0.01–0.5 mcg/kg/min · Arrest 1 mg IV/IO q3–5 min · Anaphylaxis 0.3–0.5 mg IM (1 mg/mL), repeat q5–15 min | Third-line in septic shock; first-line in anaphylaxis and post-cardiotomy low output. Raises lactate (β₂) — lactate less reliable. |
| Phenylephrine | Bolus 50–200 mcg IV · Infusion 0.1–3 mcg/kg/min (10–200 mcg/min) | Pure α₁. Useful in tachyarrhythmia-limited hypotension, HOCM, aortic stenosis. Reflex bradycardia; may lower CO. |
| Dopamine | 2–20 mcg/kg/min (β at 5–10, α >10) | More arrhythmias than norepinephrine (SOAP II); reserved for bradycardic hypotension. "Renal-dose" dopamine has no benefit. |
| Dobutamine | 2.5–20 mcg/kg/min | β₁ inotrope with β₂ vasodilation; can drop MAP. Cardiogenic shock / low CO with adequate MAP. Tachyphylaxis after 48–72 h. |
| Milrinone | 0.125–0.75 mcg/kg/min (bolus 50 mcg/kg rarely used in ICU) | PDE-3 inhibitor: inotrope + vasodilator; RV failure, pulmonary HTN, β-blocked patients. Renally cleared — reduce dose in AKI; long half-life. |
| Angiotensin II (Giapreza) | Start 20 ng/kg/min, titrate q5 min; max 80 ng/kg/min first 3 h, then 1.25–40 ng/kg/min | Refractory distributive shock (ATHOS-3). Increased VTE — anticoagulate. Consider in ACE-inhibitor overdose/vasoplegia. |
| Isoproterenol | 2–10 mcg/min (0.01–0.2 mcg/kg/min) | Pure β agonist: bradycardia/heart block bridge to pacing, torsades. Vasodilates. |
| Methylene blue | 1–2 mg/kg IV over 15–30 min (± 0.5 mg/kg/h) | Vasoplegia (post-bypass, refractory septic shock): inhibits NO/guanylate cyclase. Contraindicated with SSRIs (serotonin syndrome) and G6PD deficiency. |
| Hydroxocobalamin | 5 g IV over 15 min | Also used off-label for vasoplegia (NO scavenging) and is the cyanide antidote. |
| Source: Surviving Sepsis Campaign 2021 & 2026; SCCM/ACCM vasopressor reviews; ATHOS-3 (NEJM 2017); SOAP II (NEJM 2010); AHA CPR/ECC Guidelines 2025. | ||
Antihypertensives, vasodilators & antiarrhythmics
| Drug | Dose | Pearls |
|---|---|---|
| Nicardipine | Start 5 mg/h; ↑ 2.5 mg/h q5–15 min; max 15 mg/h | Dihydropyridine CCB. Hypertensive emergency, aortic dissection (after β-blockade), ICH/SAH BP control. Reflex tachycardia; long half-life once loaded. |
| Clevidipine | Start 1–2 mg/h; double q90 s; usual 4–6 mg/h; max 32 mg/h (≤21 mg/h avg per 24 h) | Ultra-short (1 min) lipid emulsion CCB. Contraindicated in soy/egg allergy, severe aortic stenosis; caution in pancreatitis/hyperlipidemia. |
| Esmolol | 500 mcg/kg bolus over 1 min, then 50–300 mcg/kg/min | Ultra-short β₁ blocker (t½ 9 min). Aortic dissection first (HR <60, SBP 100–120), thyroid storm, perioperative tachycardia. |
| Labetalol | 10–20 mg IV over 2 min, repeat/double q10 min (max 300 mg cumulative); infusion 0.5–2 mg/min | α₁ + β blocker (1:7). Pregnancy, stroke BP targets, aortic injury. Avoid in asthma, cocaine, heart block. |
| Hydralazine | 10–20 mg IV q4–6 h | Direct arteriolar dilator; unpredictable, reflex tachycardia — less favored in ICU titration. |
| Nitroglycerin | 5–200 mcg/min (up to 400); SL 0.4 mg | Venodilator: ACS, pulmonary edema (high dose), hypertensive emergency with heart failure. Tolerance at 24–48 h; avoid with PDE-5 inhibitors and RV infarction. |
| Nitroprusside | 0.3–0.5 mcg/kg/min, titrate to max 10 mcg/kg/min (limit 2 mcg/kg/min if prolonged) | Arterial + venous dilator; cyanide/thiocyanate toxicity with high dose, renal failure, >48–72 h. Raises ICP. |
| Amiodarone | Arrest: 300 mg IV push, then 150 mg · Stable VT/AF: 150 mg over 10 min, then 1 mg/min × 6 h, 0.5 mg/min × 18 h (PO 400 mg TID load) | Class III (multi-channel). Hypotension with bolus (solvent). Pulmonary, thyroid, hepatic toxicity; ↑ warfarin/digoxin levels; QT prolongation. |
| Lidocaine | 1–1.5 mg/kg IV bolus (repeat 0.5–0.75 mg/kg), then 1–4 mg/min | Alternative to amiodarone in VF/pVT. Neurotoxicity (seizures) especially with hepatic dysfunction or low CO. |
| Adenosine | 6 mg rapid IV push + flush; then 12 mg × 2 if needed | Stable narrow-complex SVT. Half-life <10 s; central line: use 3 mg. Avoid in WPW with AF, transplant hearts (↓ dose), severe asthma. |
| Diltiazem | 0.25 mg/kg IV (≈20 mg) over 2 min; repeat 0.35 mg/kg (≈25 mg) in 15 min; infusion 5–15 mg/h | Rate control in AF/flutter with preserved EF. Avoid in reduced EF, WPW, hypotension. |
| Metoprolol | 2.5–5 mg IV q5 min × 3; PO 25–100 mg q6–12 h | Rate control; postoperative AF; ACS. Avoid in acute decompensated HF, shock, bronchospasm. |
| Digoxin | Load 0.5 mg IV, then 0.25 mg q6 h × 2 (total 0.75–1.5 mg); maintenance 0.125–0.25 mg/day | Rate control when hypotensive/low EF (slow onset). Renally cleared; toxicity with hypokalemia, hypomagnesemia; DigiFab for toxicity. |
| Procainamide | 20–50 mg/min IV until arrhythmia stops, hypotension, QRS ↑ 50%, or 17 mg/kg; then 1–4 mg/min | Stable wide-complex tachycardia and pre-excited AF (WPW). Hypotension, lupus-like syndrome. |
| Magnesium sulfate | Torsades: 2 g IV over 1–2 min (arrest) or 15 min; repletion 1–4 g IV over 1–4 h | Target Mg >2 mg/dL in arrhythmia. Also eclampsia (4–6 g load, 1–2 g/h) and severe asthma (2 g). |
| Atropine | 1 mg IV q3–5 min (max 3 mg) | Symptomatic bradycardia. Ineffective in transplanted hearts and infranodal block — go to pacing/epinephrine/dopamine. |
| Source: AHA CPR/ECC Guidelines 2025 (Adult ALS); ACC/AHA Atrial Fibrillation Guideline 2023; ACC/AHA Hypertension Guideline 2017; Lexicomp/package inserts. | ||
ACLS & resuscitation
AHA 2025 Guidelines for CPR and ECC (adult BLS/ALS, special circumstances, post-arrest care). Energies are biphasic.
| Situation / drug | Dose or setting | Pearls |
|---|---|---|
| Cardiac arrest | ||
| CPR quality targets | Rate 100–120/min, depth 5–6 cm, full recoil, chest-compression fraction >60–80%, pauses <10 s; with advanced airway 1 breath q6 s (10/min) | Titrate to ETCO₂ ≥20 mmHg (<10 after 20 min of good CPR = poor prognosis if no reversible cause) or arterial diastolic ≥25 mmHg. Abrupt sustained ETCO₂ rise (≥40) = ROSC. Mechanical CPR devices: no survival benefit. |
| Defibrillation (VF/pVT) | Biphasic 120–200 J (device-specific) or maximum; monophasic 360 J; resume CPR immediately for 2 min after each shock | Shock before drugs. Refractory VF (≥3 shocks): vector change (anterior-posterior) or double sequential defibrillation — usefulness "not well established" (2025, COR 2b, despite DOSE-VF); most "refractory" VF is actually recurrent VF. Esmolol and ECPR are options. Do not stack shocks (except post-cardiac surgery). |
| Epinephrine | 1 mg IV/IO q3–5 min | IV is first-line access; IO if IV fails (2025). Non-shockable: give as early as possible. Shockable: after the 2nd shock. Higher or escalating doses do not improve outcomes. Vasopressin (40 U) alone or with steroids: no survival benefit — not recommended routinely. |
| Amiodarone / Lidocaine | Amiodarone 300 mg IV/IO push, then 150 mg once · Lidocaine 1–1.5 mg/kg, then 0.5–0.75 mg/kg (max 3 mg/kg) | For VF/pVT unresponsive to defibrillation (after 3rd shock); equivalent survival to discharge (ALPS). Continue whichever achieved ROSC as an infusion. |
| Magnesium | 1–2 g IV/IO push (torsades); 2 g over 10–15 min if pulse | Only for torsades de pointes / polymorphic VT with long QT and hypomagnesemia; no benefit in undifferentiated arrest. |
| Calcium / Bicarbonate | CaCl₂ 1 g (10 mL 10%) or Ca gluconate 3 g · NaHCO₃ 1 mEq/kg | NOT routine (2023/2025: recommends against). Indicated for hyperkalemia, calcium-channel blocker or hypermagnesemia arrest (calcium); hyperkalemia, TCA/sodium-channel blocker, salicylate (bicarbonate). |
| Reversible causes (H's & T's) | Hypovolemia, hypoxia, H⁺ (acidosis), hypo/hyperkalemia, hypothermia · Tension pneumothorax, tamponade, toxins, thrombosis (coronary, pulmonary) | PEA/asystole are diagnoses to explain. POCUS during the pulse check (≤10 s) for tamponade, RV dilation (PE), pneumothorax, cardiac standstill — not for prognosis alone. |
| Special: pulmonary embolism | Alteplase 50 mg IV bolus (repeat once at 15 min) or tenecteplase 0.5 mg/kg; CPR ≥60–90 min after lysis | Confirmed or strongly suspected PE arrest; surgical/catheter embolectomy or ECPR if available. |
| Special: hyperkalemia | CaCl₂ 1 g (repeat q5–10 min while QRS wide), NaHCO₃ 50–100 mEq, insulin 10 U + D50 25 g, albuterol 10–20 mg nebulized; emergent dialysis | Sine-wave/wide QRS in a dialysis patient — treat empirically. Calcium lasts 30–60 min. |
| Special: hypothermia | <30 °C: up to 3 shocks, withhold drugs, CPR and active internal/ECMO rewarming · 30–35 °C: double drug intervals | Not dead until warm (≥32 °C) and dead. K⁺ >12 mmol/L = non-survivable (asphyxia before cooling). ECMO rewarming yields best neurologic outcomes. |
| Special: pregnancy (>20 wk) | Manual left uterine displacement; IV above the diaphragm; standard drugs/energies; resuscitative hysterotomy started at 4 min, delivery by 5 min | Perimortem cesarean at the site of arrest relieves aortocaval compression; do not delay for fetal monitoring or transport. |
| Special: toxins | Opioid: naloxone 0.4–2 mg (respiratory arrest with pulse) · LAST: 20% lipid 1.5 mL/kg · Na-channel blockers: NaHCO₃ 1–2 mEq/kg · β-blocker/CCB: calcium, high-dose insulin, glucagon, ECMO | Poisoning-induced arrest: prolonged CPR and early VA-ECMO are justified (toxin is cleared over hours). Standard ACLS drugs otherwise; see the toxicology table. |
| Special: post-cardiac surgery (CALS/STS) | VF: up to 3 stacked shocks before CPR · Asystole/bradycardia: pace at maximum output · PEA: exclude tamponade/tension PTX · Emergency resternotomy within 5 min if no ROSC | Epinephrine in reduced doses (50–100 mcg) — full doses cause hypertension and graft disruption after ROSC. Internal massage via resternotomy is the definitive rescue. |
| Special: LVAD | Check power/driveline/controller, listen for hum, ETCO₂ and Doppler MAP; compressions if no pump function; defibrillate as usual | AHA 2017 statement: chest compressions are appropriate when the pump has failed; an unresponsive patient with a working pump (hum, MAP >50, ETCO₂ >20) needs a neuro/metabolic work-up, not CPR. |
| Special: traumatic arrest | Bilateral finger thoracostomy, hemorrhage control, blood, resuscitative thoracotomy (penetrating chest <15 min CPR; blunt <10 min with signs of life) | Address obstructive/hemorrhagic causes; epinephrine and closed compressions have limited value. REBOA for sub-diaphragmatic hemorrhage (not thoracic). |
| ECPR (VA-ECMO during CPR) | Selected patients: witnessed arrest, bystander CPR, shockable rhythm or reversible cause, age generally <70–75, cannulation <60 min from arrest | 2023/2025: reasonable in selected patients in systems that can deliver it (ARREST, Prague OHCA). Requires a defined pathway and rapid cannulation. |
| Termination of resuscitation | BLS rule: not witnessed by EMS, no shock delivered, no ROSC · ALS rule adds: unwitnessed by bystander, no bystander CPR | Also weigh ETCO₂ <10 mmHg after 20 min, duration >30–40 min without reversible cause, cardiac standstill on POCUS, and goals of care. Never terminate a hypothermic or toxin-related arrest early. |
| Post-cardiac arrest care | ||
| Hemodynamics & ventilation | MAP ≥65 mmHg (avoid hypotension); SpO₂ 90–98% / PaO₂ 60–105 mmHg (AHA 2025; avoid hypoxemia and hyperoxia); PaCO₂ 35–45 mmHg; glucose 140–180 mg/dL | 12-lead ECG immediately: STEMI → emergent angiography; no STEMI → not routinely emergent (COACT, TOMAHAWK). Treat seizures (cEEG for comatose patients); no prophylactic antiepileptics. |
| Temperature control | Deliberate temperature control 32–37.5 °C for ≥36 h total in patients not following commands (AHA 2025); prevent fever (>37.7 °C) — ERC/ESICM 2025: for 36–72 h; rewarm ≤0.25–0.5 °C/h | After TTM2: any target in range; the essentials are avoiding fever and a device with feedback. Shivering: acetaminophen, buspirone, magnesium, meperidine, sedation, paralysis. |
| Neuroprognostication | ≥72 h after normothermia and off sedation, multimodal: pupillary/corneal reflexes, SSEP N20, EEG (highly malignant patterns), NSE (>60 mcg/L at 48–72 h), CT/MRI, status myoclonus | Require ≥2 concordant predictors; account for renal/hepatic drug clearance and hypothermia. Early myoclonus alone is not sufficient. |
| Bradycardia & tachycardia with a pulse | ||
| Bradycardia (symptomatic) | Atropine 1 mg IV q3–5 min (max 3 mg) → transcutaneous pacing, dopamine 5–20 mcg/kg/min, or epinephrine 2–10 mcg/min → transvenous pacing | Atropine fails in infranodal block (wide QRS, Mobitz II, 3rd-degree) and transplanted hearts. Inferior STEMI block: pace and reperfuse; avoid β-agonists in ischemia if pacing captures. |
| Synchronized cardioversion | Narrow regular (SVT/flutter) 50–100 J · Narrow irregular (AF) ≥200 J initial (AHA 2025) · Wide regular (VT) 100 J · Wide irregular → defibrillate (unsynchronized) | Any unstable tachyarrhythmia (hypotension, altered mentation, ischemia, heart failure). Sedate if conscious. Escalate energy stepwise. |
| Adenosine | 6 mg rapid IV push with 20 mL flush, then 12 mg | Stable regular narrow-complex SVT (or regular monomorphic wide-complex as diagnostic/therapeutic). Contraindicated in irregular or pre-excited (WPW) tachycardia. Reduce dose with dipyridamole, carbamazepine, transplanted heart, central line. |
| Stable wide-complex tachycardia | Procainamide 20–50 mg/min until termination, hypotension, QRS ↑ >50%, or 17 mg/kg; then 1–4 mg/min · Amiodarone 150 mg over 10 min, then 1 mg/min · Sotalol 100 mg (1.5 mg/kg) over 5 min | Procainamide preferred if WPW; avoid AV-nodal blockers (adenosine, CCB, digoxin, β-blockers) with pre-excited AF. Avoid procainamide/sotalol with long QT or heart failure. |
| Torsades de pointes (with pulse) | Magnesium 2 g IV over 10–15 min; K⁺ to >4; isoproterenol 2–10 mcg/min or overdrive pacing at 90–110/min; stop QT-prolonging drugs | Defibrillate if pulseless or unstable. Class IA/III antiarrhythmics are contraindicated (prolong QT). |
| Anaphylaxis | Epinephrine 0.3–0.5 mg IM (1 mg/mL) q5–15 min; refractory: IV infusion 1–10 mcg/min; crystalloid 1–2 L; glucagon 1–5 mg if β-blocked | Never 1 mg IV push in a patient with a pulse. Antihistamines/steroids are adjuncts. Secure the airway early with angioedema/stridor. |
| Source: 2025 AHA Guidelines for CPR and ECC — Part 9 Adult ALS, Part 10 Special Circumstances, Part 11 Post–Cardiac Arrest Care (Circulation 2025); 2023 AHA Focused Update on Adult ACLS (Perman, Circulation 2024); ERC/ESICM Post-Resuscitation Care 2025; AHA 2017 Statement on CPR in Patients With Mechanical Circulatory Support; STS Expert Consensus on Resuscitation After Cardiac Surgery 2017; EAST/WTA Resuscitative Thoracotomy guidelines; ERC/ESICM Post-Resuscitation Care 2021. | ||
Sedation, analgesia & induction
| Drug | Dose | Pearls |
|---|---|---|
| Propofol | Sedation 5–50 mcg/kg/min (max ~80) · Induction 1–2.5 mg/kg (0.5–1 in shock/elderly) | GABA. Hypotension, hypertriglyceridemia (check TG q3–4 days; 1.1 kcal/mL), pancreatitis, PRIS (>4 mg/kg/h × >48 h: acidosis, bradycardia, rhabdo). Propofol or dexmedetomidine over benzodiazepines (PADIS); short-acting for neuro exams. |
| Dexmedetomidine | 0.2–1.5 mcg/kg/h (optional load 1 mcg/kg over 10 min — usually omitted) | α₂ agonist; arousable sedation, no respiratory depression, analgesic-sparing. Bradycardia and hypotension; not for deep sedation alone. PADIS 2025: suggested over propofol when light sedation and/or delirium reduction are the priority. Useful for withdrawal and extubation. |
| Midazolam | Bolus 0.5–2 mg (up to 0.05 mg/kg) · Infusion 0.01–0.1 mg/kg/h (1–7 mg/h) | Benzodiazepine; accumulates with renal failure, obesity, CYP3A4 inhibitors → prolonged sedation, delirium. Reserve for seizures, withdrawal, deep sedation needs. |
| Lorazepam | 0.5–2 mg IV q2–6 h; infusion 0.5–2 mg/h (rare) | Propylene glycol toxicity (osmolar gap, lactic acidosis) at high infusion rates. Status epilepticus 0.1 mg/kg (max 4 mg/dose). |
| Ketamine | Induction 1–2 mg/kg IV (4–5 mg/kg IM) · Analgosedation 0.1–0.5 mg/kg/h · Sub-dissociative analgesia 0.1–0.3 mg/kg | NMDA antagonist: preserves respiratory drive and BP (catecholamine release; can drop BP in catecholamine-depleted shock). Bronchodilator. Emergence phenomena, hypersalivation. ICP concern largely disproven. |
| Etomidate | 0.3 mg/kg IV induction | Hemodynamically neutral; adrenal suppression (11β-hydroxylase) 24–48 h after a single dose; myoclonus. No infusion. |
| Fentanyl | Bolus 25–100 mcg IV q30–60 min · Infusion 25–200 mcg/h (0.7–10 mcg/kg/h) | Rapid onset, no active metabolites, safe in renal failure; lipophilic — accumulates with prolonged infusion. Chest wall rigidity with large rapid boluses. Serotonin syndrome with SSRIs/linezolid. |
| Hydromorphone | 0.2–1 mg IV q1–3 h · Infusion 0.5–3 mg/h · PCA 0.2 mg q6–10 min | ~7× morphine potency; fewer active metabolites than morphine — preferred in renal impairment among the morphinans. |
| Morphine | 2–5 mg IV q1–2 h · Infusion 2–10 mg/h · PCA 1 mg q6–10 min | Histamine release (hypotension, bronchospasm); morphine-6-glucuronide accumulates in renal failure → prolonged sedation. Avoid in AKI. |
| Remifentanil | 0.05–0.2 mcg/kg/min (no bolus in ICU) | Esterase-metabolized, context-insensitive half-life (3–10 min) — ideal for frequent neuro checks; hyperalgesia on abrupt discontinuation. |
| Acetaminophen | 1 g IV/PO q6 h (max 4 g/day; 2–3 g/day in liver disease, low weight, alcohol use) | Multimodal foundation; IV offers no clear advantage over PO/PR if gut works. Hypotension reported with IV in critically ill. |
| Ketorolac | 15–30 mg IV q6 h (15 mg if >65 y, <50 kg, or CrCl reduced); max 5 days | NSAID: AKI, bleeding, GI ulceration; avoid in hypovolemia, AKI, anastomotic concerns per surgeon preference. |
| Gabapentin | 100–300 mg PO TID, titrate (renal adjust) | Neuropathic pain, opioid-sparing; sedation, respiratory depression with opioids. |
| Haloperidol | 0.5–5 mg IV/IM q30 min–6 h PRN | Agitation; no benefit on delirium duration (MIND-USA). QTc prolongation, EPS, NMS. Check QTc >500 ms. |
| Quetiapine | 25–50 mg PO q12 h, titrate to 200 mg/day | Off-label for ICU delirium; sedating, orthostasis, QTc. Stop at discharge. |
| Naloxone | 0.04–0.4 mg IV, titrate q2–3 min to 2 mg (0.4–2 mg for apnea); infusion ⅔ of effective bolus per hour | Opioid reversal; precipitates withdrawal — use low doses in opioid-tolerant. Duration 30–90 min, shorter than most opioids. |
| Flumazenil | 0.2 mg IV over 30 s; repeat 0.2 mg q1 min to 1 mg | Benzodiazepine reversal; seizures in chronic benzodiazepine users, TCA co-ingestion — rarely used in ICU. |
| Source: SCCM PADIS Guidelines 2018 (Devlin et al., Crit Care Med) & 2025 Focused Update (Lewis et al., Crit Care Med 2025); SCCM Clinical Practice Guidelines for Sustained NMB 2016; Lexicomp; Marino's The ICU Book, 4th ed. | ||
Neuromuscular blockers & reversal
| Drug | Dose | Pearls |
|---|---|---|
| Succinylcholine | 1–1.5 mg/kg IV (3–4 mg/kg IM); onset 45–60 s, duration 5–10 min | Depolarizing. K⁺ rises ~0.5 mEq/L; contraindicated with hyperkalemia risk: burns/crush/denervation/immobilization >24–72 h (up to 1–2 years), neuromuscular disease, malignant hyperthermia history. Bradycardia (children, repeat dose). Prolonged with pseudocholinesterase deficiency. |
| Rocuronium | RSI 1–1.2 mg/kg (onset 60 s); intubation 0.6 mg/kg; infusion 8–12 mcg/kg/min (0.3–0.6 mg/kg/h) | Aminosteroid; hepatic elimination — prolonged in hepatic failure. Reversible with sugammadex. Preferred RSI alternative to succinylcholine. |
| Vecuronium | 0.08–0.1 mg/kg bolus; infusion 0.8–1.7 mcg/kg/min | Aminosteroid; hepatic + renal (active 3-desacetyl metabolite accumulates in renal failure). Sugammadex-reversible. |
| Cisatracurium | 0.1–0.2 mg/kg bolus; infusion 1–3 mcg/kg/min (ARDS trials: 37.5 mg/h fixed × 48 h) | Benzylisoquinolinium; Hofmann elimination (organ-independent) — agent of choice in hepatic/renal failure. Laudanosine metabolite (seizures, theoretical). Not reversible with sugammadex. |
| Sugammadex | 2 mg/kg (TOF ≥2 twitches) · 4 mg/kg (deep block, PTC 1–2) · 16 mg/kg (immediate reversal after 1.2 mg/kg rocuronium) | Binds rocuronium > vecuronium; not cisatracurium/succinylcholine. Anaphylaxis, bradycardia; reduces hormonal contraceptive efficacy 7 days; caution CrCl <30. |
| Neostigmine + glycopyrrolate | Neostigmine 0.03–0.07 mg/kg (max 5 mg) with glycopyrrolate 0.2 mg per 1 mg neostigmine (or atropine 0.4 mg/mg) | Reverse only when TOF ≥2–4 twitches; ceiling effect. Also neostigmine 2–2.5 mg IV for Ogilvie syndrome (with atropine at bedside). |
| Dantrolene | 2.5 mg/kg IV, repeat q5–10 min to effect (cumulative up to 10 mg/kg+); then 1 mg/kg q4–6 h × 24–48 h | Malignant hyperthermia (Ryanodex 250 mg vials dissolve faster). Also NMS adjunct. Hepatotoxicity; avoid with CCBs (hyperkalemia). |
| Source: SCCM Guidelines for Sustained NMB in the Adult Critically Ill Patient 2016; ACURASYS (NEJM 2010); ROSE (NEJM 2019); MHAUS; Miller's Anesthesia. | ||
Anticoagulation, reversal & hemostasis
| Drug | Dose | Pearls |
|---|---|---|
| Unfractionated heparin | Prophylaxis 5,000 U SC q8–12 h · Therapeutic (VTE) 80 U/kg bolus, 18 U/kg/h; (ACS) 60 U/kg (max 4,000), 12 U/kg/h · target aPTT 1.5–2.5× or anti-Xa 0.3–0.7 | Preferred when CrCl <30 or reversal may be needed. HIT (5–10 days; 4T score). Reverse with protamine. |
| Enoxaparin | Prophylaxis 40 mg SC daily (30 mg q12h trauma/ortho/BMI >40; anti-Xa 0.2–0.4 goal) · Therapeutic 1 mg/kg q12 h (1.5 mg/kg daily) · CrCl <30: 30 mg daily / 1 mg/kg daily | Renal clearance; anti-Xa monitoring in renal failure, obesity, pregnancy. Partially reversed by protamine (1 mg per 1 mg within 8 h; 0.5 mg/mg after). |
| Fondaparinux | 2.5 mg SC daily (prophylaxis); 5/7.5/10 mg daily by weight (<50 / 50–100 / >100 kg) | Option in HIT. Contraindicated CrCl <30 and <50 kg. No reversal agent (rFVIIa anecdotal). |
| Argatroban | 2 mcg/kg/min; 0.5 mcg/kg/min in hepatic dysfunction, critical illness, post-cardiac surgery; aPTT 1.5–3× baseline | Direct thrombin inhibitor for HIT; hepatic clearance. Raises INR — target INR >4 on combined therapy when bridging to warfarin, then recheck 4–6 h after stopping. |
| Bivalirudin | 0.15–0.2 mg/kg/h (HIT, off-label); PCI 0.75 mg/kg bolus + 1.75 mg/kg/h; ECMO 0.03–0.05 mg/kg/h | DTI; enzymatic + renal clearance (reduce with CrCl <30). Short half-life (25 min). Stasis clotting in circuits. |
| Warfarin | 2.5–10 mg PO daily; INR 2–3 (2.5–3.5 mechanical mitral) | Vitamin K antagonist; skin necrosis (protein C) — overlap with heparin ≥5 days. Many interactions. |
| Apixaban / Rivaroxaban | Apixaban 10 mg BID × 7 d then 5 mg BID (VTE); 2.5–5 mg BID (AF) · Rivaroxaban 15 mg BID × 21 d then 20 mg daily | Factor Xa inhibitors; reverse with 4F-PCC 25–50 U/kg (the US reversal agent since andexanet's withdrawal, Dec 2025). Avoid rivaroxaban CrCl <15; hold 2–5 days pre-op by renal function. |
| Dabigatran | 150 mg BID (75 mg BID CrCl 15–30) | DTI; reverse with idarucizumab 5 g IV (2 × 2.5 g); dialyzable. |
| Protamine | 1 mg per 100 U UFH given in the last 2–3 h (max 50 mg, ≤5 mg/min) | Hypotension, anaphylaxis (NPH insulin, fish allergy, vasectomy), pulmonary hypertension. Excess protamine is itself anticoagulant. |
| Vitamin K (phytonadione) | Major bleed: 10 mg IV slow (over 20–30 min) · INR >10 no bleed: 2.5–5 mg PO · INR 4.5–10: hold warfarin ± 1–2.5 mg PO | Onset 6–12 h IV (24 h PO); IV anaphylactoid reactions (rare, slow infusion). Give with PCC for durable reversal. |
| 4F-PCC (Kcentra) | INR 2–3.9: 25 U/kg · 4–6: 35 U/kg · >6: 50 U/kg (max 2,500/3,500/5,000 U); fixed 1,500–2,000 U regimens used · Xa-inhibitor bleeding (off-label, now first-line in the US): 25–50 U/kg or fixed 2,000 U | Factors II, VII, IX, X + protein C/S + heparin. Onset 10–30 min; thrombosis risk. Contraindicated in HIT (contains heparin) and DIC. |
| Andexanet alfa — withdrawn in the US | No longer available in the US (Andexxa withdrawn Dec 2025 after FDA safety review). Former regimen, still used where marketed (EU: Ondexxya): 400 mg bolus then 4 mg/min × 2 h, or 800 mg then 8 mg/min × 2 h for higher/recent doses | Factor Xa decoy. ANNEXA-I (ICH): better hemostasis but thrombosis 14.6% vs 6.9% and more thrombotic deaths than usual care (mostly PCC) — the basis for withdrawal. Use 4F-PCC for Xa-inhibitor bleeding in the US. Also interfered with heparin (post-reversal anticoagulation, bypass). |
| Idarucizumab | 5 g IV (two 2.5 g vials within 15 min) | Dabigatran-specific monoclonal antibody fragment; can redose if rebleeding with elevated dTT. |
| Tranexamic acid | Trauma: 1 g IV over 10 min, then 1 g over 8 h (within 3 h of injury) · TBI (CRASH-3) same · Surgery: 10–15 mg/kg ± 1 mg/kg/h · Postpartum 1 g | Antifibrinolytic; seizures at high doses (cardiac surgery); avoid >3 h after trauma (harm). Renal adjust. |
| Desmopressin (DDAVP) | 0.3 mcg/kg IV over 15–30 min (hemostasis) · DI: 1–2 mcg IV/SC q8–12 h or 10–40 mcg intranasal | Releases vWF/factor VIII: uremic platelet dysfunction, vWD type 1, antiplatelet-associated ICH (controversial). Hyponatremia, tachyphylaxis. |
| Alteplase (tPA) | Massive PE: 100 mg over 2 h (or 50 mg) · Stroke: 0.9 mg/kg (max 90 mg), 10% bolus, rest over 60 min, within 4.5 h (tenecteplase 0.25 mg/kg bolus is an equal Class 1 option, AHA/ASA 2026) · STEMI: 15 mg bolus, 0.75 mg/kg (≤50) over 30 min, 0.5 mg/kg (≤35) over 60 min · Catheter clearance 2 mg | Hold heparin during infusion for PE; ICH 2–6%. Contraindications: recent surgery/trauma, ICH history, active bleeding. |
| Cryoprecipitate / fibrinogen concentrate | Cryo 10 units (1 pool/5–10 units raises fibrinogen ~50–100 mg/dL) · Fibrinogen concentrate 2–4 g | Target fibrinogen >150–200 mg/dL in massive hemorrhage/obstetric bleeding (per TEG/ROTEM). |
| Aspirin / P2Y₁₂ reversal | Platelets 1 apheresis unit (not for ICH on antiplatelets — PATCH showed harm); DDAVP 0.3 mcg/kg | Ticagrelor is reversible (bentracimab investigational); platelet transfusion ineffective for ticagrelor. |
| Source: CHEST Antithrombotic Guidelines; ACC Expert Consensus on Management of Bleeding in Patients on Oral Anticoagulants (2020); ASH VTE/HIT Guidelines 2018; CRASH-2 (Lancet 2010); PROPPR (JAMA 2015); EAST VTE Prophylaxis Guidelines (2022); ANNEXA-I (NEJM 2024) & FDA/AstraZeneca withdrawal of Andexxa from the US market (Dec 2025). | ||
Antiplatelets & thrombolytics
| Drug | Dose | Pearls |
|---|---|---|
| Antiplatelet agents | ||
| Aspirin | ACS: 162–325 mg chewed once, then 81 mg daily · Stroke: 160–325 mg within 24–48 h (after tPA window) · Post-CEA/stent/CABG: 81 mg daily | Irreversible COX-1 inhibitor; platelet effect lasts 7–10 days (platelet lifespan). Continue perioperatively in most vascular/cardiac patients (POISE-2: no benefit starting it, but stopping raises stent-thrombosis risk). Reye's, GI bleeding; PR route if NPO. |
| Clopidogrel | Load 300–600 mg PO, then 75 mg daily | P2Y₁₂ prodrug (CYP2C19 — poor metabolizers, omeprazole interaction). Irreversible; hold 5 days before elective surgery. TTP (rare). Weakest of the P2Y₁₂ agents. |
| Ticagrelor | Load 180 mg, then 90 mg BID (60 mg BID after 12 months) | Reversible direct P2Y₁₂ inhibitor, but hold 3–5 days pre-op (drug persists). Dyspnea (14%), bradyarrhythmias; aspirin must be ≤100 mg. Platelet transfusion does not reverse it (circulating drug inhibits new platelets); bentracimab investigational. |
| Prasugrel | Load 60 mg, then 10 mg daily (5 mg if < 60 kg or ≥ 75 y) | Irreversible; most potent; hold 7 days pre-op. Contraindicated with prior stroke/TIA; more bleeding than clopidogrel (TRITON-TIMI 38). |
| Cangrelor | 30 mcg/kg IV bolus, then 4 mcg/kg/min (PCI); bridging 0.75 mcg/kg/min | IV reversible P2Y₁₂ inhibitor; offset in ~1 h — used to bridge stented patients who must stop oral P2Y₁₂ agents for surgery (BRIDGE trial). Give oral agent at infusion end. |
| Eptifibatide / Tirofiban | Eptifibatide 180 mcg/kg bolus ×2 (10 min apart), 2 mcg/kg/min (1 mcg/kg/min CrCl < 50) · Tirofiban 25 mcg/kg bolus, 0.15 mcg/kg/min | GP IIb/IIIa inhibitors (reversible; platelet function recovers 4–8 h). PCI/ACS adjuncts, bridging. Thrombocytopenia (check platelets at 6 h); renal dosing. Abciximab (irreversible, 24–48 h) is largely unavailable. |
| Dipyridamole (+ ASA) | 200 mg ER / 25 mg ASA BID | Secondary stroke prevention alternative; headache. Not for perioperative use. |
| Antiplatelet reversal | Platelets 1 apheresis unit — not for spontaneous ICH on antiplatelets (PATCH: worse outcomes); reasonable before emergent neurosurgery per institutional protocol · DDAVP 0.3 mcg/kg IV (aspirin/clopidogrel, uremia) | Time is the only reliable reversal: aspirin 7–10 d, clopidogrel 5–7 d, prasugrel 7–10 d, ticagrelor 3–5 d. Platelet transfusion is ineffective for ticagrelor and cangrelor while drug circulates. |
| Perioperative DAPT after stent | Minimum DAPT before non-cardiac surgery: BMS 30 days; DES 6 months (3 months if surgical delay is risky; 1 month with newer DES in select cases); continue aspirin throughout when possible; resume P2Y₁₂ within 24–72 h | 2016 ACC/AHA DAPT focused update & 2024 perioperative guideline. Stent thrombosis mortality 20–45%. Bridge with cangrelor/tirofiban when interruption is unavoidable early after stenting. |
| Thrombolytics | ||
| Alteplase (tPA) | Massive PE: 100 mg IV over 2 h (50 mg over 2 h alternative; 0.6 mg/kg max 50 mg over 15 min in arrest) · Ischemic stroke: 0.9 mg/kg (max 90), 10% bolus over 1 min, remainder over 60 min, within 4.5 h · STEMI (no PCI within 120 min): 15 mg bolus, 0.75 mg/kg (≤ 50) over 30 min, 0.5 mg/kg (≤ 35) over 60 min · Catheter occlusion: 2 mg/2 mL dwell · Empyema: 10 mg intrapleural BID × 3 d with DNase 5 mg (MIST2) | Fibrin-specific serine protease; half-life 5 min. Hold heparin during PE infusion, restart when aPTT < 2× control. ICH 1–6% (higher in elderly, low weight, hypertension). Angioedema (ACE-inhibitor users). |
| Tenecteplase (TNK) | Stroke: 0.25 mg/kg IV single bolus (max 25 mg) · STEMI: weight-tiered bolus 30–50 mg (0.5 mg/kg; half dose if ≥ 75 y) · PE (off-label, PEITHO): same weight-tiered bolus | Longer half-life, more fibrin-specific, single bolus — AHA/ASA 2026: tenecteplase 0.25 mg/kg or alteplase 0.9 mg/kg are both Class 1 within 4.5 h (AcT, TRACE-2, EXTEND-IA TNK); simpler bolus favored before transfer/thrombectomy. Do not use the 0.4 mg/kg stroke dose (more sICH). Same contraindications. |
| Reteplase | 10 U IV bolus ×2, 30 min apart (STEMI) | Non-weight-based double bolus; mostly historical; used in some catheter-directed protocols. |
| Catheter-directed thrombolysis | PE: alteplase 1 mg/h per catheter × 12–24 h (total 12–24 mg; ultrasound-assisted per ULTIMA/SEATTLE II) · Limb ischemia (Rutherford IIa): alteplase 0.5–1 mg/h intra-arterial with sub-therapeutic heparin (aPTT 1.2–1.5×) · DVT (iliofemoral): 0.5–1 mg/h (ATTRACT: less post-thrombotic syndrome in iliofemoral only) | Lower systemic dose; check fibrinogen q6 h (hold if < 100–150 mg/dL). Intermediate-high-risk PE: CDT vs anticoagulation alone is the subject of ongoing trials (HI-PEITHO, PEERLESS). |
| Absolute contraindications (systemic lysis) | Prior ICH; known structural cerebrovascular lesion or malignant intracranial neoplasm; ischemic stroke within 3 months (except acute stroke < 4.5 h); suspected aortic dissection; active bleeding or bleeding diathesis; significant closed-head/facial trauma within 3 months; intracranial/spinal surgery within 2 months; severe uncontrolled hypertension unresponsive to therapy | Relative: SBP > 180/110, recent major surgery (< 3 wk), internal bleeding (2–4 wk), non-compressible punctures, pregnancy, active peptic ulcer, anticoagulation, prolonged CPR (> 10 min), dementia. In arrest from confirmed massive PE, lysis is given despite CPR (continue CPR 60–90 min after). |
| Thrombolytic reversal (bleeding) | Stop infusion; cryoprecipitate 10 units (target fibrinogen > 150 mg/dL); TXA 1 g IV or aminocaproic acid 4–5 g load then 1 g/h; platelets if on antiplatelets or < 100k; FFP if INR elevated; CT head immediately if neurologic change (AHA 2019 sICH protocol) | Symptomatic ICH after stroke lysis ~2–6%; angioedema 1–5% (treat with antihistamines/steroids, icatibant/C1-esterase inhibitor, airway). |
| Source: 2016 ACC/AHA DAPT Focused Update; 2024 ACC/AHA Perioperative Cardiovascular Guideline; 2026 AHA/ASA Acute Ischemic Stroke Guideline; 2019 ESC PE Guideline & PEITHO (NEJM 2014); PATCH (Lancet 2016); BRIDGE (JAMA 2012); ATTRACT (NEJM 2017); MIST2 (NEJM 2011); Lexicomp. | ||
Antimicrobials
Empiric ICU regimens (normal renal function). De-escalate at 48–72 h on cultures; reassess duration daily. Renal dose-adjust all except: ceftriaxone, linezolid, moxifloxacin, azithromycin, doxycycline, metronidazole, clindamycin, nafcillin, and echinocandins.
| Drug | Dose | Spectrum / pearls |
|---|---|---|
| Gram-positive / MRSA | ||
| Vancomycin | Load 20–35 mg/kg IV (actual weight, max 3 g), then 15–20 mg/kg q8–12 h; target AUC₂₄/MIC 400–600 (trough 15–20 historically); 1 g q12 h if uncomplicated | MRSA, MRSE, enterococci (not VRE), C. diff (PO only). Nephrotoxicity ↑ with piperacillin-tazobactam; infusion reaction ("vancomycin flushing") — slow rate. Poor lung/CNS penetration. |
| Linezolid | 600 mg IV/PO q12 h | MRSA, VRE, toxin suppression. Thrombocytopenia (>2 wk), serotonin syndrome (SSRIs, fentanyl, meperidine), lactic acidosis, optic neuropathy. Preferred over vanc for MRSA pneumonia by some data. 100% oral bioavailability. |
| Daptomycin | 6–10 mg/kg IV q24 h (8–12 for bacteremia/endocarditis); q48 h if CrCl <30 | MRSA, VRE bacteremia/endocarditis, skin. Inactivated by surfactant — never for pneumonia. CK weekly (myopathy); eosinophilic pneumonia. |
| Ceftaroline | 600 mg IV q12 h (q8 h for bacteremia) | 5th-gen cephalosporin: MRSA + typical gram-negatives (no Pseudomonas). MRSA pneumonia alternative. |
| Nafcillin / Oxacillin | 2 g IV q4 h | Drug of choice for MSSA bacteremia/endocarditis (or cefazolin 2 g q8 h — better tolerated). Interstitial nephritis, neutropenia. |
| Clindamycin | 600–900 mg IV q8 h | Toxin suppression in necrotizing fasciitis/TSS (add to β-lactam); anaerobes above the diaphragm, MSSA/CA-MRSA (check D-test). C. diff risk. |
| Ampicillin | 2 g IV q4–6 h | Enterococcus faecalis (with gentamicin or ceftriaxone for endocarditis), Listeria (meningitis >50 y). |
| Broad-spectrum β-lactams (anti-pseudomonal) | ||
| Piperacillin-tazobactam | 4.5 g IV q6 h (or 4.5 g q8 h as 4-h extended infusion); load 4.5 g over 30 min first | Gram-negative incl. Pseudomonas, anaerobes, enterococci (faecalis), MSSA. Intra-abdominal sepsis, HAP/VAP, NSTI. AKI with vancomycin; sodium load; seizures in renal failure. |
| Cefepime | 2 g IV q8 h (1–2 g q12 h if CrCl 30–60; 1 g q24 h <30); 2 g q8 h extended infusion for Pseudomonas | 4th-gen: Pseudomonas, Enterobacterales (incl. AmpC — but not ESBL); no anaerobes. Neurotoxicity (encephalopathy, myoclonus, NCSE) with renal impairment — a favorite exam pitfall. |
| Ceftazidime | 2 g IV q8 h | Pseudomonas; weak gram-positive activity. Ceftazidime-avibactam 2.5 g q8 h for CRE (KPC/OXA-48), MDR Pseudomonas. |
| Meropenem | 1 g IV q8 h (2 g q8 h meningitis/CF/extended infusion over 3 h); 500 mg q8 h with CrCl 26–50 | ESBL, AmpC producers, Pseudomonas, anaerobes; not MRSA, VRE, Stenotrophomonas. Seizure risk lower than imipenem; ↓ valproate levels dramatically. |
| Imipenem-cilastatin | 500 mg–1 g IV q6 h | Broadest; seizures (renal failure, CNS lesions). Ertapenem 1 g daily: no Pseudomonas/Acinetobacter/enterococcus — good for ESBL outpatient/step-down. |
| Aztreonam | 2 g IV q8 h | Gram-negatives incl. Pseudomonas only; safe in severe penicillin allergy (except ceftazidime cross-reactivity via shared side chain). |
| Other gram-negative coverage | ||
| Ceftriaxone | 1–2 g IV q24 h (2 g q12 h meningitis) | CAP, pyelonephritis, SBP (1 g), variceal bleed prophylaxis, meningitis (+ vanc ± ampicillin). No Pseudomonas/enterococcus. Biliary sludge; avoid with calcium in neonates. |
| Gentamicin / Tobramycin | Once-daily 5–7 mg/kg (adjusted body weight if obese); traditional 1.7–2 mg/kg q8 h; synergy 1 mg/kg q8 h (endocarditis) | Concentration-dependent killing; nephro-/ototoxicity; neuromuscular blockade. Amikacin 15–20 mg/kg daily. Poor lung penetration; not for monotherapy of Pseudomonas pneumonia. |
| Ciprofloxacin / Levofloxacin | Cipro 400 mg IV q8–12 h (750 PO BID) · Levo 750 mg IV/PO q24 h | Pseudomonas (cipro > levo), atypicals (levo/moxi). QT prolongation, tendinopathy, aortic aneurysm/dissection warning, C. diff, delirium; dysglycemia. Rising resistance — avoid empiric use where possible. |
| Azithromycin | 500 mg IV/PO q24 h (× 3–5 days) | Atypical CAP coverage with ceftriaxone; immunomodulatory. QT prolongation. |
| Doxycycline | 100 mg IV/PO q12 h | CA-MRSA skin, atypicals, rickettsia, Vibrio (with ceftriaxone), leptospirosis. No renal adjustment. |
| TMP-SMX | 8–10 mg/kg/day (TMP) IV divided q6–8 h; PJP 15–20 mg/kg/day | Stenotrophomonas drug of choice, CA-MRSA, PJP (+ prednisone if PaO₂ <70), Nocardia. Hyperkalemia, ↑ creatinine (tubular secretion), marrow suppression. |
| Polymyxin B / Colistin | Polymyxin B 2.5 mg/kg load, then 1.25–1.5 mg/kg q12 h · Colistin (CMS) 300 mg CBA load, then 150–180 mg q12 h (renal adjust) | Last-line for carbapenem-resistant Acinetobacter/Pseudomonas/CRE; nephro-/neurotoxic. Newer agents preferred when active: ceftazidime-avibactam, meropenem-vaborbactam, imipenem-relebactam, cefiderocol; sulbactam-durlobactam (+ carbapenem) for CRAB (IDSA AMR guidance 2024). |
| Anaerobes, C. difficile, fungi, viruses | ||
| Metronidazole | 500 mg IV/PO q8 h (or 1 g q12 h); fulminant C. diff 500 mg IV q8 h with PO vancomycin | Anaerobes below the diaphragm, amebiasis, giardiasis. Disulfiram reaction, peripheral neuropathy (prolonged), ↑ INR with warfarin. Not for aspiration pneumonia monotherapy. |
| Vancomycin (oral) | 125 mg PO q6 h × 10 d · Fulminant: 500 mg PO/NG q6 h + IV metronidazole 500 mg q8 h ± 500 mg in 100 mL rectal q6 h if ileus | C. difficile: fidaxomicin 200 mg BID × 10 d is preferred for initial and recurrent episodes (IDSA/SHEA 2021); oral vancomycin is an acceptable alternative and the agent for fulminant disease. Not absorbed. Surgery (subtotal colectomy or diverting loop ileostomy + lavage) for toxic megacolon, perforation, refractory shock, lactate >5. |
| Fluconazole | 800 mg (12 mg/kg) IV/PO load, then 400 mg (6 mg/kg) daily | C. albicans, cryptococcus consolidation, Candida UTI (only azole with urinary levels). Poor against C. glabrata/krusei/auris. QT, hepatotoxicity, CYP interactions (tacrolimus, warfarin). |
| Micafungin / Caspofungin | Micafungin 100 mg IV daily · Caspofungin 70 mg load, then 50 mg daily | Echinocandins: first-line for candidemia and invasive candidiasis in ICU (IDSA); no renal adjustment. Poor CNS/eye/urine penetration. |
| Amphotericin B (liposomal) | 3–5 mg/kg IV daily (5–10 for mucormycosis) | Mucormycosis (plus surgical debridement), cryptococcal meningitis (+ flucytosine), refractory candidiasis. Nephrotoxicity, K⁺/Mg²⁺ wasting, infusion reactions; saline-load. |
| Voriconazole | 6 mg/kg IV q12 h × 2, then 4 mg/kg q12 h (PO 200–300 mg BID); trough 1–5.5 mcg/mL | Invasive aspergillosis first-line. Visual disturbance, hepatotoxicity, QT, photosensitivity; IV vehicle (cyclodextrin) accumulates CrCl <50. Many CYP interactions. |
| Acyclovir | 10 mg/kg IV q8 h (HSV encephalitis, 14–21 d); 5 mg/kg q8 h mucocutaneous | Crystal nephropathy — hydrate, ideal body weight, renal adjust. Start empirically for encephalitis before PCR. |
| Oseltamivir | 75 mg PO BID × 5 d (longer in critical illness/immunocompromised) | Start regardless of symptom duration in hospitalized influenza. Renal adjust CrCl <60. |
| Ganciclovir | 5 mg/kg IV q12 h induction (14–21 d), then 5 mg/kg daily | CMV disease in transplant/immunocompromised; marrow suppression (neutropenia), nephrotoxicity; foscarnet if resistant. |
| Common empiric regimens | ||
| Septic shock, unknown source | Vancomycin + piperacillin-tazobactam (or cefepime/meropenem) within 1 h; add antifungal if high risk (TPN, prior broad abx, perforation, colonization) | Every hour of delay increases mortality. Cultures before antibiotics if no delay. Prolonged (extended/continuous) β-lactam infusion for maintenance after the loading dose (SSC 2026: strong recommendation). Source control within 6–12 h. |
| HAP / VAP | Piperacillin-tazobactam or cefepime or meropenem ± vancomycin/linezolid (MRSA risk: prior IV abx within 90 d, unit MRSA prevalence >10–20%) ± second anti-pseudomonal if septic shock/high resistance; 7 days | IDSA/ATS 2016. Use local antibiogram. Procalcitonin to guide stopping. |
| Complicated intra-abdominal infection | Community: ceftriaxone + metronidazole or piperacillin-tazobactam · Healthcare-associated/severe: piperacillin-tazobactam or meropenem ± vancomycin ± echinocandin; 4 days after source control (STOP-IT) | Enterococcal coverage for healthcare-associated, immunocompromised, valvular disease, or post-op recurrent infection. |
| Necrotizing soft tissue infection | Vancomycin + piperacillin-tazobactam (or carbapenem) + clindamycin 900 mg q8 h; penicillin G 4 million U q4 h + clindamycin for group A strep | Immediate surgical debridement is definitive; re-look in 24 h. Clindamycin suppresses toxin (Eagle effect). |
| Bacterial meningitis (adult) | Ceftriaxone 2 g q12 h + vancomycin (± ampicillin 2 g q4 h if >50 y/immunocompromised) + dexamethasone 0.15 mg/kg q6 h × 4 d (before/with first dose); post-neurosurgical: vancomycin + cefepime/meropenem | Don't delay antibiotics for LP/CT. Dexamethasone benefits pneumococcal meningitis. |
| Aspiration pneumonia | Ampicillin-sulbactam 3 g q6 h, or ceftriaxone ± metronidazole; piperacillin-tazobactam if HAP risk | Aspiration pneumonitis (chemical) needs no antibiotics; reassess at 48 h. |
| Open fracture prophylaxis | Cefazolin 2 g IV q8 h (3 g if >120 kg) for Gustilo I–II (24 h); add gram-negative coverage (e.g., ceftriaxone or piperacillin-tazobactam) for type III; penicillin for farm/soil contamination | Give within 1 h of injury (EAST). Continue 72 h or 24 h after wound closure for type III. |
| Source: Surviving Sepsis Campaign 2021 & 2026; IDSA/ATS HAP/VAP Guidelines 2016; IDSA Guidance on Antimicrobial-Resistant Gram-Negative Infections 2024; IDSA Candidiasis 2016 & Aspergillosis 2016; IDSA/SHEA C. difficile 2021 update; SIS/IDSA Intra-abdominal Infection 2017 & STOP-IT (NEJM 2015); IDSA Skin and Soft Tissue 2014; Sanford Guide 2025; ASHP/IDSA Vancomycin Consensus 2020; EAST Open Fracture Guideline 2011. | ||
Electrolytes, endocrine & metabolic
| Drug | Dose | Pearls |
|---|---|---|
| Insulin (regular) infusion | ICU hyperglycemia: start when glucose >180; target 140–180 mg/dL · DKA/HHS: 0.1 U/kg/h fixed rate (bolus optional) once K⁺ >3.5 mmol/L (2024 consensus; formerly 3.3); add D5 when glucose <250 (DKA) / <300 (HHS) | NICE-SUGAR: tight control (81–108) ↑ mortality. Hypokalemia, hypophosphatemia. Hyperkalemia: 10 U IV + 25–50 g dextrose (monitor glucose 4–6 h). |
| Hydrocortisone | Septic shock: 200 mg/day (50 mg q6 h or continuous) · Adrenal crisis: 100 mg IV then 50 q6 h / 200 mg/day · Stress dosing for chronic steroid users: 50–100 mg q8 h | Surviving Sepsis 2026 suggests IV corticosteroids in septic shock (conditional); usual trigger is ongoing vasopressor need (NE/epi ≥0.25 mcg/kg/min ≥4 h, SSC 2021). Fludrocortisone 50 mcg optional (APROCCHSS). Taper over days when shock resolves. Hyperglycemia, myopathy, hypernatremia. |
| Dexamethasone | Meningitis 0.15 mg/kg q6 h × 4 d · Cerebral edema (tumor) 10 mg IV then 4 mg q6 h · COVID/ARDS 6 mg daily × 10 d · PONV 4–8 mg | No mineralocorticoid effect — inappropriate for adrenal crisis alone. Do not use in TBI (CRASH: ↑ mortality). |
| Methylprednisolone | ARDS (early, moderate–severe): 1 mg/kg/day taper (Meduri) · Spinal cord injury: not recommended · Pulse: 1 g daily × 3 | ATS 2024 ARDS guideline: corticosteroids suggested for ARDS (conditional). DEXA-ARDS supports dexamethasone 20 mg × 5 d, 10 mg × 5 d. Avoid starting >14 d after ARDS onset. |
| Levothyroxine | Myxedema coma: 200–400 mcg IV load (lower in elderly/CAD), then 50–100 mcg IV daily (1.6 mcg/kg PO ≈ 75% IV); ± liothyronine 5–20 mcg then 2.5–10 mcg q8 h | Give hydrocortisone first. Passive rewarming; avoid over-aggressive warming (vasodilation). |
| Propylthiouracil / Methimazole | Thyroid storm: PTU 500–1,000 mg load, then 250 mg q4 h (or methimazole 20 mg q4–6 h); iodine (SSKI 5 drops q6 h or Lugol's 10 drops q8 h) ≥1 h later; propranolol 60–80 mg q4–6 h or esmolol; hydrocortisone 100 mg q8 h | PTU blocks T4→T3 conversion (preferred in storm, 1st trimester); hepatotoxicity. Methimazole for maintenance. |
| Potassium chloride | IV 10 mEq/h peripheral, 20 mEq/h central (up to 40 with monitoring); 10 mEq raises K⁺ ~0.1 mEq/L; PO 40 mEq doses | Correct Mg²⁺ first (refractory hypokalemia). Target K⁺ ≥4 in cardiac patients. Use KPhos if hypophosphatemic. |
| Magnesium sulfate | 1–2 g IV over 1 h (mild); 4 g over 4 h (severe/symptomatic; 2 g push in torsades); eclampsia 4–6 g load then 1–2 g/h | Renal excretion — half dose in AKI. Target >2 mg/dL in arrhythmias/hypokalemia. Toxicity: loss of reflexes → give calcium. |
| Calcium | Gluconate 1–2 g IV over 10 min (3 g for hyperkalemia with ECG changes; 1 g = 93 mg elemental) · Chloride 1 g IV central (272 mg elemental, 3×) · Massive transfusion: 1 g CaCl per 2–4 units | Correct for albumin or check ionized Ca (<1.1 mmol/L treat if symptomatic/bleeding/on pressors). Calcium chloride peripheral extravasation → necrosis. Do not mix with bicarbonate/phosphate. |
| Phosphate (Na or K phos) | Serum PO₄ 2–2.5: 0.16 mmol/kg; 1–2: 0.32 mmol/kg; <1: 0.64 mmol/kg IV over 4–6 h (max ~30–45 mmol/dose); PO 250–500 mg (8–16 mmol) TID | Use ideal body weight in obesity. KPhos delivers 4.4 mEq K⁺/3 mmol PO₄ (limit K⁺ rate). Hypophosphatemia: refeeding, DKA, respiratory failure to wean, CRRT. |
| Sodium bicarbonate | 50–100 mEq (1–2 amps of 8.4%) IV; infusion 150 mEq in 1 L D5W · BICAR-ICU: target pH ≥7.30 in pH ≤7.20 with AKI · Hyperkalemia 50 mEq · TCA overdose 1–2 mEq/kg bolus, target pH 7.50–7.55 | Each amp 50 mEq Na⁺/1,000 mOsm. Generates CO₂ — ventilate; hypocalcemia, hypernatremia. In DKA only if pH <7.0 (2024 consensus); not for routine lactic acidosis. |
| Hypertonic saline (3%) | Symptomatic hyponatremia: 100–150 mL bolus over 10–20 min, repeat ×2 (goal ↑4–6 mEq/L; ≤8 per 24 h) · ICP: 250 mL 3% or 30 mL 23.4% (central) over 10–20 min; infusion 3% 0.5–1 mL/kg/h to Na 145–155 | Peripheral 3% acceptable short-term. Monitor Na q2–4 h; osm <320, Na <160. Overcorrection → D5W + DDAVP 2 mcg. |
| Mannitol | 0.25–1 g/kg IV over 15–20 min; repeat q4–6 h; hold if osm >320 or osm gap >20 | Osmotic diuretic — causes hypovolemia/hypotension (avoid in shock); rebound; AKI. Hypertonic saline preferred in hypovolemic/hyponatremic patients. Needs intact BBB and filter. |
| Hyperkalemia bundle | Calcium (above) → insulin 10 U + D50 25–50 g → albuterol 10–20 mg neb → NaHCO₃ if acidotic → furosemide 40–80 mg IV → patiromer 8.4 g / SZC 10 g TID → dialysis | Membrane stabilization (minutes) → shift (15–30 min, 1 mEq/L) → removal. Recheck K⁺ q1–2 h. Sodium polystyrene is slow and associated with colonic necrosis. |
| Thiamine | Wernicke: 500 mg IV TID × 2–3 d, then 250 mg daily · Prophylaxis/refeeding/alcohol: 100–200 mg IV daily · Septic shock: 200 mg q12 h was studied as adjunct (with vitamin C/hydrocortisone) — no outcome benefit (VICTAS, ATESS); SSC suggests against IV vitamin C | Give before or with dextrose. Also for beriberi-associated lactic acidosis with TPN/malnutrition. |
| Vasopressin (DI) / Desmopressin | DDAVP 1–2 mcg IV/SC q8–12 h (titrate to UOP <200–300 mL/h); vasopressin 0.5–2.5 U/h infusion in brain-dead donors | Central DI after TBI/pituitary surgery/brain death: UOP >300 mL/h × 2 h, Na ↑, urine osm <300. Replace free water deficit. |
| Source: NICE-SUGAR (NEJM 2009); Surviving Sepsis Campaign 2021 & 2026; ADRENAL & APROCCHSS (NEJM 2018); ADA/EASD/JBDS/AACE/DTS Hyperglycemic Crises Consensus 2024; ATS ARDS Guideline 2024; Verbalis et al. Hyponatremia Guidelines (Am J Med 2013); BICAR-ICU (Lancet 2018); ATA Thyroid Guidelines 2016; KDIGO; Lexicomp. | ||
Neurocritical care
| Drug | Dose | Pearls |
|---|---|---|
| Lorazepam / Midazolam (status epilepticus) | Lorazepam 0.1 mg/kg IV (max 4 mg/dose, repeat once) · Midazolam 10 mg IM (>40 kg) or 0.2 mg/kg · Diazepam 0.15–0.2 mg/kg IV (max 10 mg) or 20 mg PR | First-line at 5 min of seizure. Under-dosing is the commonest error (RAMPART, ESETT). |
| Levetiracetam | 60 mg/kg IV (max 4,500 mg) over 10 min (status) · 1,000–1,500 mg BID maintenance · TBI prophylaxis 500–1,000 mg BID × 7 d | Second-line, equivalent to fosphenytoin/valproate (ESETT). Renal adjust; behavioral side effects. Preferred over phenytoin for post-traumatic seizure prophylaxis (no monitoring). |
| Fosphenytoin / Phenytoin | Fosphenytoin 20 mg PE/kg IV at ≤150 mg PE/min · Phenytoin 20 mg/kg at ≤50 mg/min · maintenance 100 mg q8 h; free level 1–2 mcg/mL | Hypotension/arrhythmia with rapid infusion (phenytoin's propylene glycol; "purple glove"). Correct level for albumin. Many interactions; not for toxic seizures (theophylline, TCAs). |
| Valproate | 20–40 mg/kg IV (max 3,000 mg) at 10 mg/kg/min; maintenance 250–500 mg q8 h | Hepatotoxicity, pancreatitis, thrombocytopenia, hyperammonemia; meropenem drops levels precipitously. |
| Propofol / midazolam / ketamine (refractory SE) | Propofol 1–2 mg/kg then 30–200 mcg/kg/min · Midazolam 0.2 mg/kg then 0.05–2 mg/kg/h · Ketamine 1–3 mg/kg then 1–10 mg/kg/h | Third-line with continuous EEG; target burst suppression or seizure cessation for 24–48 h. Pentobarbital 5–15 mg/kg then 0.5–5 mg/kg/h as alternative. |
| Nimodipine | 60 mg PO/NG q4 h × 21 days (30 mg q2 h if hypotensive) | Improves outcome after aneurysmal SAH (reduces delayed cerebral ischemia). Never IV in the U.S. (fatal hypotension when given IV by error). |
| Hypertonic saline / Mannitol | See electrolytes table | Treat ICP >22 mmHg; CPP 60–70 (BTF 4th ed.). Tier: HOB 30°, sedation, osmotherapy, CSF drainage, brief hyperventilation (PaCO₂ 30–35), then barbiturates/hypothermia/decompressive craniectomy (RESCUEicp: ↓ mortality, ↑ severe disability). |
| Nicardipine / Clevidipine (ICH) | Target SBP 140 mmHg (avoid <130) within 1 h for ICH (INTERACT-2/ATACH-2); ischemic stroke <185/110 pre-tPA, <180/105 after; permissive to 220/120 if no tPA | Reverse anticoagulants (4F-PCC for warfarin and Xa inhibitors — andexanet withdrawn in the US; idarucizumab for dabigatran). Platelets contraindicated for antiplatelet-associated ICH (PATCH). |
| Aspirin / Antiplatelets (stroke) | Aspirin 325 mg within 24–48 h of ischemic stroke (after tPA window); DAPT 21 days for minor stroke/TIA (POINT/CHANCE) | Also aspirin after CEA/CAS; ticagrelor alternative. |
| Alteplase / Tenecteplase (stroke) | Alteplase 0.9 mg/kg (max 90) within 4.5 h · Tenecteplase 0.25 mg/kg (max 25 mg) single bolus — either agent is Class 1 (AHA/ASA 2026) | Thrombectomy for LVO up to 24 h (DAWN/DEFUSE-3) regardless of lytics. |
| Phenobarbital (withdrawal) | 10 mg/kg IV load (ideal body weight) over 30 min, or 130–260 mg IV q15–30 min; then 65–130 mg q8 h taper | Alternative or adjunct to benzodiazepines for severe alcohol withdrawal; long half-life (~4 days) — self-tapering. Respiratory depression with benzodiazepines. |
| Dexmedetomidine / Clonidine (withdrawal adjuncts) | Dexmedetomidine 0.2–1.5 mcg/kg/h · Clonidine 0.1–0.3 mg PO q6–8 h | Adjuncts only — do not prevent withdrawal seizures or DTs. Benzodiazepines/phenobarbital remain the backbone. |
| Source: Brain Trauma Foundation Guidelines 4th ed. (2016); AHA/ASA ICH 2022 & Acute Ischemic Stroke 2026 Guidelines; AHA/ASA aSAH 2023; Neurocritical Care Society Status Epilepticus Guideline 2012 & ESETT (NEJM 2019); ASAM Alcohol Withdrawal Guideline 2020. | ||
GI, hepatic & renal
| Drug | Dose | Pearls |
|---|---|---|
| Pantoprazole | SUP: 40 mg IV/PO daily · Upper GI bleed: 80 mg IV bolus then 8 mg/h × 72 h, or 40 mg IV q12 h (equivalent) | SUP indications: MV >48 h, coagulopathy, shock, liver disease, prior GI bleed. Stop when risk resolves. Associated with C. diff and pneumonia (small); SUP-ICU: no mortality difference; REVISE (NEJM 2024): pantoprazole ↓ clinically important GI bleeding in ventilated patients, no mortality or pneumonia difference. |
| Famotidine | 20 mg IV/PO q12 h (renal adjust) | H2 blocker alternative for SUP; thrombocytopenia (rare), delirium in elderly/renal failure. |
| Sucralfate | 1 g PO/NG q6 h | Coats mucosa; binds other drugs (separate by 2 h); aluminum accumulation in renal failure. |
| Octreotide | Variceal bleed: 50 mcg IV bolus, then 50 mcg/h × 2–5 d · High-output fistula/chyle leak: 100–200 mcg SC q8 h | Splanchnic vasoconstriction. Hyperglycemia, bradycardia, gallstones. Terlipressin alternative (also HRS). |
| Erythromycin / Metoclopramide | Erythromycin 250 mg IV q6 h (or 3 mg/kg) × ≤3–5 d · Metoclopramide 10 mg IV q6 h (renal adjust) | Prokinetics for feeding intolerance/gastroparesis; erythromycin before EGD for bleeding (250 mg IV 30–60 min prior). Tachyphylaxis; QT prolongation; metoclopramide EPS/tardive dyskinesia. |
| Lactulose | 20–30 g (30–45 mL) PO/NG q1–2 h until stool, then TID–QID titrated to 2–3 soft stools/day; enema 300 mL in 700 mL water | Hepatic encephalopathy first-line; add rifaximin 550 mg BID for secondary prevention. Avoid over-diarrhea (hypernatremia, volume depletion). |
| Albumin | SBP: 1.5 g/kg on day 1, 1 g/kg on day 3 · Large-volume paracentesis (>5 L): 6–8 g per L removed · HRS: 1 g/kg (max 100 g) then 20–40 g/day with terlipressin/vasoconstrictors | No benefit over crystalloid for sepsis resuscitation (ALBIOS, SAFE); harmful in TBI (SAFE-TBI). |
| Terlipressin | HRS-AKI: 1 mg IV q6 h (0.85 mg), titrate to 2 mg q6 h with albumin (CONFIRM) | FDA-approved 2022; respiratory failure risk — avoid with volume overload or SpO₂ <90%. Alternative: norepinephrine or midodrine 7.5–15 mg TID + octreotide. |
| N-acetylcysteine | Acetaminophen: 150 mg/kg IV over 1 h, 50 mg/kg over 4 h, 100 mg/kg over 16 h (21-h protocol); continue if LFTs rising · Non-APAP ALF: same regimen (benefit in early-grade encephalopathy) | Most effective within 8 h; anaphylactoid reactions (slow first bag). PO 140 mg/kg then 70 mg/kg q4 h × 17 doses. |
| Furosemide | 20–80 mg IV bolus (2–2.5× home oral dose; up to 200 mg if AKI/diuretic-resistant); infusion 5–20 mg/h (after loading bolus) | Loop diuretic (1 mg IV ≈ 2 mg PO). Bolus vs infusion equivalent (DOSE). Ototoxicity with rapid high doses; hypokalemia/hypomagnesemia; contraction alkalosis. Sulfa allergy — use ethacrynic acid. |
| Bumetanide / Torsemide | Bumetanide 0.5–2 mg IV (1 mg ≈ 40 mg furosemide); infusion 0.5–2 mg/h · Torsemide 10–40 mg IV/PO (20 mg ≈ 40 mg furosemide) | Better oral bioavailability than furosemide (torsemide ~80–100%). |
| Chlorothiazide / Metolazone | Chlorothiazide 250–500 mg IV q12 h · Metolazone 5–10 mg PO 30 min before loop | Sequential nephron blockade for loop-diuretic resistance; profound hypokalemia/hyponatremia — monitor closely. |
| Acetazolamide | 250–500 mg IV/PO q8–12 h × 1–3 days | Post-diuretic metabolic (contraction) alkalosis; carbonic anhydrase inhibitor. Hypokalemia; avoid in cirrhosis (ammonia), sulfa allergy. |
| CRRT anticoagulation | Regional citrate (ACD-A ~150–180 mL/h prefilter; target post-filter iCa 0.25–0.35 mmol/L, systemic iCa 1.1–1.3) or heparin 5–10 U/kg/h (aPTT 35–45 s) | Citrate preferred (KDIGO) unless liver failure/shock with lactate >8 (citrate accumulation: total/ionized Ca ratio >2.5). Dose 20–25 mL/kg/h effluent. |
| Source: ACG Upper GI Bleeding 2021; AASLD Portal Hypertensive Bleeding 2017, HRS & ALF guidances; SUP-ICU (NEJM 2018); REVISE (NEJM 2024); DOSE (NEJM 2011); KDIGO AKI 2012; STARRT-AKI (NEJM 2020); ASPEN/SCCM Nutrition Guidelines 2016/2022. | ||
Immunosuppression & transplant critical care
| Drug / situation | Dose & targets | Pearls |
|---|---|---|
| Maintenance agents | ||
| Tacrolimus | PO 0.05–0.1 mg/kg/day divided BID (XR once daily); trough 8–12 ng/mL early, 5–8 late (organ/protocol specific) · IV continuous 0.03–0.05 mg/kg/day (≈¼–⅕ of oral) · Sublingual ≈½ oral dose | Calcineurin inhibitor (CNI). Nephrotoxicity (afferent vasoconstriction), hyperkalemia (type 4 RTA), hypomagnesemia, hyperglycemia, tremor, PRES, TMA, QT prolongation. CYP3A4/P-gp substrate: ↑ by azoles, macrolides, diltiazem/verapamil, amiodarone, protease inhibitors, grapefruit; ↓ by rifampin, phenytoin, carbamazepine, St John's wort. Never bolus IV (vehicle anaphylaxis). |
| Cyclosporine | PO 4–8 mg/kg/day divided BID; trough 150–300 ng/mL early, 50–150 late (C2 monitoring in some programs) · IV ≈⅓ of oral dose as continuous infusion | CNI: same nephrotoxicity/hypertension/hyperkalemia plus gingival hyperplasia, hirsutism, hyperlipidemia. Raises statin levels (OATP1B1) — rhabdomyolysis with simvastatin/lovastatin/high-dose atorvastatin. Same CYP3A4 interactions as tacrolimus. |
| Mycophenolate | Mofetil 1–1.5 g PO/IV BID (IV = PO dose) · Mycophenolic acid (EC) 720 mg BID; no routine levels | Antimetabolite (IMPDH inhibitor). Leukopenia, GI toxicity (diarrhea, colitis — mimics CMV), teratogenic (contraindicated in pregnancy; switch to azathioprine). Hold first in infection, BK viremia, PTLD. Levels ↓ with PPIs (mofetil) and cyclosporine. |
| Azathioprine | 1–2.5 mg/kg/day PO/IV | Prodrug of 6-MP. Marrow suppression, hepatotoxicity, pancreatitis. Allopurinol/febuxostat (xanthine-oxidase inhibitors) → fatal myelosuppression unless dose cut to ¼–⅓ — avoid the combination. TPMT/NUDT15 deficiency ↑ toxicity. Safe in pregnancy. |
| Sirolimus / Everolimus | Sirolimus 2–5 mg load then 1–3 mg daily; trough 4–12 ng/mL · Everolimus 0.75–1.5 mg BID; trough 3–8 ng/mL | mTOR inhibitors. Impaired wound healing, dehiscence, lymphocele, hernia — hold around surgery. Pneumonitis, hyperlipidemia, proteinuria, mouth ulcers, edema, cytopenias, HUS with CNIs. Not nephrotoxic per se; used to reduce CNI exposure and in malignancy. |
| Belatacept | 10 mg/kg IV days 1, 5, then wk 2, 4, 8, 12; then 5 mg/kg q4 wk | CTLA-4-Ig costimulation blocker (kidney). No nephrotoxicity, no levels. Contraindicated in EBV-seronegative recipients (CNS PTLD); higher early rejection rates; PML reported. |
| Prednisone / stress dosing | Maintenance 5–10 mg/day (or steroid-free) · Stress: hydrocortisone 50 mg IV q6 h or 100 mg q8 h during shock/major surgery, taper over 2–3 days | Any patient on ≥5 mg prednisone for >3 weeks has HPA suppression. Adrenal crisis presents as refractory hypotension, hyponatremia, hyperkalemia, hypoglycemia. |
| Induction & rejection therapy | ||
| Methylprednisolone pulse | 500–1,000 mg IV daily × 3 days, then taper | First-line for acute cellular rejection (all organs). Steroid-resistant cellular rejection → ATG. |
| Antithymocyte globulin (rabbit) | Induction 1–1.5 mg/kg/day × 3–5 days (total 4.5–6 mg/kg); rejection 1.5 mg/kg/day × 7–14 days; via central line over 6–12 h with premedication | Polyclonal T-cell depletion. Cytokine-release syndrome (fever, rigors, hypotension, pulmonary edema), leukopenia/thrombocytopenia (hold for WBC <2,000–3,000, plt <50,000–75,000), serum sickness (1–2 wk), ↑ CMV/PTLD. Equine ATG (Atgam) is a different product/dose. |
| Basiliximab | 20 mg IV within 2 h pre-transplant and on day 4 | IL-2 receptor (CD25) antibody; non-depleting, well tolerated; for low/standard immunologic risk induction. |
| Alemtuzumab | 30 mg IV/SC × 1–2 doses (off-label induction) | Anti-CD52; profound, prolonged T- and B-cell depletion (months). Infusion reactions, autoimmunity, infections. |
| Antibody-mediated rejection | Plasmapheresis (5–6 sessions) + IVIG 100 mg/kg after each (or 2 g/kg) + rituximab 375 mg/m²; refractory: bortezomib 1.3 mg/m², eculizumab 900–1,200 mg | Diagnosed by donor-specific antibodies + C4d/microvascular inflammation on biopsy. Eculizumab requires meningococcal vaccination/prophylaxis. Pulse steroids are given concurrently. |
| Prophylaxis & opportunistic infection | ||
| CMV | Prophylaxis: valganciclovir 900 mg daily (renally adjusted) for 3–6 mo (D+/R− kidney: 200 days; lung 6–12 mo); letermovir (kidney) 480 mg daily · Treatment: ganciclovir 5 mg/kg IV q12 h or valganciclovir 900 mg BID ≥2 wk and until PCR negative | Late CMV after prophylaxis ends is common. Tissue-invasive disease (colitis, pneumonitis, hepatitis) → IV ganciclovir + reduce antimetabolite. Resistance (UL97/UL54) after ≥2 wk of therapy without response → foscarnet, maribavir. Ganciclovir: neutropenia. |
| Pneumocystis | TMP-SMX SS daily or DS three times weekly for 6–12 mo (lifelong in lung/after ATG per protocol); alternatives atovaquone 1,500 mg daily, dapsone 100 mg, inhaled pentamidine · Treatment: TMP-SMX 15–20 mg/kg/day (TMP) IV ÷ q6–8 h × 21 days + prednisone if PaO₂ <70 | TMP-SMX also covers Nocardia (partially), Toxoplasma, Listeria. Hyperkalemia and creatinine rise (tubular secretion block) with TMP-SMX + CNI. |
| Fungal | Nystatin/clotrimazole for oral candidiasis 1–3 mo; fluconazole 400 mg or echinocandin in liver/pancreas/small bowel with risk factors; voriconazole/posaconazole/isavuconazole or inhaled amphotericin in lung transplant | Azoles raise CNI/mTOR levels 2–5× — reduce dose empirically (tacrolimus ↓ ~50% with fluconazole, ↓ ~66% with voriconazole/posaconazole) and check troughs in 2–3 days. Echinocandins have no CNI interaction. |
| BK polyomavirus (kidney) | Screen plasma PCR monthly to 9 mo, then q3 mo to 2 yr; viremia >10⁴ copies/mL → reduce antimetabolite by 50% or stop, then lower CNI target | No effective antiviral. Nephropathy mimics rejection on biopsy (SV40 stain) — pulse steroids worsen it. Also hemorrhagic cystitis in stem-cell recipients. |
| EBV / PTLD | Reduce immunosuppression (stop antimetabolite, CNI −50%); rituximab 375 mg/m² weekly × 4 for CD20⁺; CHOP-type chemotherapy if refractory | Risk: EBV D+/R−, ATG/alemtuzumab, belatacept. Antivirals do not treat established PTLD. |
| Nocardia / Cryptococcus / Listeria | Nocardia: TMP-SMX 15 mg/kg/day + imipenem ± amikacin (CNS/severe), 6–12 mo · Cryptococcal meningitis: liposomal AmB 3–4 mg/kg + flucytosine 25 mg/kg q6 h ≥2 wk, then fluconazole; daily LPs for ICP · Listeria: ampicillin 2 g q4 h ± gentamicin | Reduce immunosuppression gradually (abrupt withdrawal → IRIS/rejection). Rifampin for any indication crashes CNI levels. |
| Organ-specific emergencies | ||
| Kidney | Delayed graft function (dialysis in 1st week; biopsy if no recovery by ~7–10 d) · Renal artery/vein thrombosis (sudden anuria, reversed diastolic flow) → immediate re-exploration · Urine leak/lymphocele → drain, stent · Hyperkalemia: CNI + TMP-SMX + ACEi | Daily Doppler early. Rising creatinine ddx: CNI toxicity, rejection, BK, obstruction, TMA, dehydration — biopsy decides. Hypotension harms the graft: avoid MAP <70 in the first days. |
| Liver | Hepatic artery thrombosis (rising AST/INR, no bile) → urgent revascularization or re-listing (status 1A ≤7 d) · Primary non-function (INR >2.5, lactate ↑, coma without vascular cause) → re-transplant · Biliary leak/stricture → drain + ERCP · Ischemic cholangiopathy (DCD) → often re-transplant | Daily hepatic artery Doppler week 1 (RI 0.5–0.8; tardus-parvus = stenosis). Post-op coagulopathy is expected — do not correct INR prophylactically (portal/hepatic artery thrombosis risk). |
| Lung | Primary graft dysfunction (infiltrates ≤72 h; grade 1 P/F >300, grade 2 200–300, grade 3 <200) → lung-protective ventilation, keep dry, iNO/epoprostenol, VV-ECMO · Anastomotic dehiscence/stenosis → bronchoscopy · Acute rejection (A2+) → pulse steroids | Denervated lungs: no cough reflex — aggressive pulmonary toilet; single-lung transplant with native COPD → hyperinflation/auto-PEEP of the native lung (differential ventilation). CMV, PJP, and fungal prophylaxis are longest in lung recipients. |
| Heart | Denervated heart: resting HR 90–110, no response to atropine/carotid massage/digoxin — use isoproterenol, epinephrine, dobutamine, pacing; adenosine dose ↓ (exaggerated effect) · RV failure early → iNO, milrinone, ECMO · Cardiac allograft vasculopathy → silent ischemia, heart failure | Bradycardia after transplant is abnormal. Endomyocardial biopsy for rejection surveillance; donor-specific antibodies/AMR → plasmapheresis/IVIG. |
| Pancreas / intestine | Pancreas: graft venous thrombosis (sudden hyperglycemia, pain) or duodenal leak → urgent laparotomy; rising lipase/amylase or falling urinary amylase (bladder drained) = rejection · Intestine: highest rejection rate; surveillance ileoscopy/biopsy; GVHD | SPK: the kidney is the sentinel for rejection. Bladder-drained pancreas → bicarbonate loss, dehydration, reflux pancreatitis, chemical cystitis. |
| Deceased donor management | MAP ≥65, CVP 6–10 · Vasopressin 0.5–2.4 U/h first-line (also treats DI); desmopressin 1–4 mcg if DI persists (UOP >4 mL/kg/h, Na ↑) · Levothyroxine 20 mcg bolus + 10 mcg/h (or T3 4 mcg + 3 mcg/h) · Methylprednisolone 15 mg/kg · Insulin to glucose 100–180 · Na <155 · Normothermia · Lung-protective ventilation (VT 6–8 mL/kg, PEEP 8–10, recruitment) | Hormone resuscitation increases organs recovered per donor. Hypernatremia >155 worsens liver graft outcomes. Bronchoscopy and lung-protective strategy raise lung yield. DCD: withdrawal in/near OR; warm ischemia limits (kidney ~60 min, liver ~30 min). |
| Sepsis in a transplant recipient | Cultures + early broad-spectrum antibiotics (consider resistant/opportunistic organisms); hold the antimetabolite; continue CNI with daily levels (interactions, AKI); stress-dose steroids if on prednisone | Do not stop all immunosuppression. Fever may be blunted; infection and rejection can coexist. Check drug interactions with every new ICU medication (azoles, macrolides, amiodarone, diltiazem, rifampin, phenytoin). |
| Source: KDIGO Kidney Transplant Recipient Guideline 2009; AST Infectious Diseases Community of Practice Guidelines (3rd ed., 2019); ISHLT guidelines for heart and lung recipients; AASLD/AST Long-Term Management of the Liver Transplant Recipient 2013; SCCM/ACCP/AOPO Consensus on Management of the Potential Organ Donor 2015; Lexicomp; package inserts. | ||
Toxicology & antidotes
| Toxin / situation | Antidote & dose | Pearls |
|---|---|---|
| Decontamination & enhanced elimination | ||
| Activated charcoal | 1 g/kg (50–100 g) PO/NG within 1 h (later for sustained-release, large ingestions, anticholinergics/opioids); airway must be protected | Does not bind: metals (iron, lithium, potassium), alcohols, hydrocarbons, caustics ("PHAILS": pesticides, hydrocarbons, acids/alkalis, iron, lithium, solvents). Contraindicated with caustics (obscures endoscopy) and unprotected airway. |
| Multiple-dose activated charcoal | 25–50 g q2–4 h ("gut dialysis" for enterohepatic/enteroenteric recirculation) | Carbamazepine, dapsone, phenobarbital, quinine, theophylline (± amatoxin, colchicine early). Watch for ileus/aspiration. |
| Whole-bowel irrigation | Polyethylene glycol–electrolyte solution 1.5–2 L/h by NG until rectal effluent is clear | Sustained-release/enteric-coated drugs, iron, lithium, potassium, body packers (asymptomatic). Contraindicated: ileus, obstruction, perforation, hemodynamic instability, unprotected airway, caustics. |
| Urinary alkalinization | NaHCO₃ 1–2 mEq/kg bolus, then 150 mEq in 1 L D5W at 2–3× maintenance; target urine pH 7.5–8, serum pH ≤7.55; replace K⁺ (hypokalemia defeats alkalinization) | Salicylates, phenobarbital, methotrexate, chlorpropamide, 2,4-D. Not for TCAs (serum, not urine, alkalinization). |
| Hemodialysis (EXTRIP) | Dialyzable: salicylate, lithium, toxic alcohols, metformin, theophylline, valproate, carbamazepine, phenobarbital, thallium, acetaminophen (massive), atenolol/sotalol, isoniazid | Not dialyzable (large Vd or protein binding): digoxin, TCAs, most CCBs/β-blockers, opioids, benzodiazepines, colchicine, chloroquine, loperamide. Fomepizole/NAC are removed — redose during dialysis. |
| Toxidromes | ||
| Sympathomimetic | Tachycardia, hypertension, hyperthermia, mydriasis, diaphoresis, agitation, seizures; bowel sounds present | Cocaine, amphetamines, cathinones, theophylline/caffeine. Benzodiazepines first; cooling; avoid pure β-blockers with cocaine; bicarbonate for wide QRS (cocaine). |
| Anticholinergic | Tachycardia, hyperthermia, mydriasis, dry flushed skin, urinary retention, absent bowel sounds, delirium/mumbling ("dry as a bone") | Diphenhydramine, TCAs, antipsychotics, jimsonweed, scopolamine. Benzodiazepines; physostigmine 0.5–1 mg IV slow (max 2 mg) for pure anticholinergic delirium — contraindicated with QRS >100 ms, TCA, bradycardia, seizure. |
| Cholinergic | SLUDGE/DUMBELS: salivation, lacrimation, urination, diarrhea, bronchorrhea/bronchospasm, bradycardia, miosis; nicotinic: fasciculations, weakness | Organophosphates, carbamates, nerve agents, physostigmine/neostigmine excess, certain mushrooms. Atropine to dry secretions; pralidoxime (organophosphates); benzodiazepines. |
| Opioid | Miosis, respiratory depression (rate < depth), CNS depression, hypotension, hypothermia, ↓ bowel sounds | Naloxone. Mimics: clonidine/imidazolines (inconsistent naloxone response), xylazine (no response; skin ulcers), pontine hemorrhage. Chest-wall rigidity with high-dose fentanyl. |
| Sedative-hypnotic | CNS depression with normal pupils and vital signs (unless mixed); hypothermia; hyporeflexia | Benzodiazepines, barbiturates, ethanol, GHB, baclofen. Supportive; flumazenil rarely (seizures in dependence/co-ingestion). Withdrawal (benzodiazepine, GHB, baclofen) is life-threatening. |
| Serotonin syndrome | Hyperreflexia, inducible/spontaneous clonus (legs > arms), tremor, mydriasis, diaphoresis, diarrhea, hyperthermia; onset <24 h | SSRIs/SNRIs + linezolid, methylene blue, fentanyl/meperidine/tramadol, ondansetron, dextromethorphan, MAOIs, lithium. Hunter criteria. Benzodiazepines, cooling, cyproheptadine; paralysis if T >41 °C. |
| Sodium-channel blockade (wide QRS) | QRS >100–120 ms, rightward terminal 40-ms axis (tall R in aVR >3 mm), hypotension, seizures | TCAs, cocaine, diphenhydramine, propranolol, bupropion, carbamazepine, lamotrigine, flecainide, loperamide, quinine/chloroquine. Hypertonic NaHCO₃ 1–2 mEq/kg boluses to QRS <100 and pH 7.50–7.55; lipid emulsion and ECMO for refractory. |
| QT prolongation / torsades | QTc >500 ms, polymorphic VT, often pause-dependent; hypokalemia/hypomagnesemia potentiate | Methadone, antipsychotics, ondansetron, fluoroquinolones/macrolides, azoles, loperamide, sotalol, citalopram. Magnesium 2 g, K⁺ >4, isoproterenol/overdrive pacing; avoid class IA/III drugs. |
| Antidotes by toxin | ||
| Opioids | Naloxone 0.04–0.4 mg IV titrated (2 mg if apneic; up to 10 mg); infusion ⅔ effective dose/h | Goal: ventilation, not full alertness. Long-acting opioids (methadone) need infusion/observation ≥6–12 h. |
| Benzodiazepines | Flumazenil 0.2 mg IV q1 min to 1 mg (3 mg max) | Rarely indicated; seizures in dependence/TCA co-ingestion. Support airway instead. |
| Acetaminophen | NAC IV: 150 mg/kg over 1 h, 50 mg/kg over 4 h, 100 mg/kg over 16 h (don't stop automatically at 21 h: continue until APAP <10 mcg/mL, INR <2, and AST/ALT normal or ↓ 25–50% from peak) · High-risk ingestion (≥30 g or above the 300-line): double the 16-h bag (12.5 mg/kg/h; triple at the 450-line); consider fomepizole; hemodialysis per EXTRIP (e.g., level >900 mcg/mL with altered mentation + acidosis) — double NAC during HD · Charcoal 1 g/kg within 4 h if airway safe | Rumack–Matthew line: 150 mcg/mL at 4 h, halving every 4 h (75 at 8 h, 37.5 at 12 h); valid 4–24 h after a single ingestion. Repeated supratherapeutic/unknown-time: treat if APAP >20 mcg/mL or AST/ALT abnormal (2023 consensus). Anaphylactoid reaction to NAC → pause, antihistamine, restart slower (not an allergy). King's College criteria for transplant: pH <7.30, or INR >6.5 + Cr >3.4 + grade III–IV encephalopathy; lactate >3.5 (4 h) / >3.0 (12 h). |
| Salicylates | NaHCO₃ 1–2 mEq/kg bolus, then 150 mEq/L D5W at 2–3× maintenance (urine pH 7.5–8, serum pH ≤7.55); K⁺ repletion; hemodialysis if level >90–100 mg/dL, altered mental status, pulmonary edema, renal failure, or clinical deterioration | Avoid intubation if possible (hyperventilation is compensatory); if intubated, match minute ventilation. Glucose to the brain — give dextrose if any neuro symptoms. |
| Tricyclic antidepressants | NaHCO₃ 1–2 mEq/kg boluses for QRS >100 ms, arrhythmia, or hypotension; target pH 7.50–7.55; lipid emulsion for refractory | Sodium channel blockade. Avoid class IA/IC/III antiarrhythmics and physostigmine. Norepinephrine for hypotension. |
| β-blockers | Glucagon 3–10 mg IV bolus, then 3–5 mg/h; high-dose insulin 1 U/kg bolus then 1–10 U/kg/h with D10–D50 infusion; calcium; catecholamines; lipid emulsion; pacing/ECMO | Glucagon causes vomiting — protect airway. Propranolol: sodium-channel effects → bicarbonate; sotalol → torsades. |
| Calcium-channel blockers | Calcium chloride 1–2 g (or gluconate 3–6 g) IV, repeat; high-dose insulin as above (first-line); norepinephrine/epinephrine; methylene blue or lipid emulsion for refractory vasoplegia; ECMO | Hyperglycemia with normal mental status suggests CCB (vs β-blocker: hypoglycemia). Whole-bowel irrigation for extended-release. |
| Digoxin | Digoxin immune Fab: acute known dose — vials = mg ingested × 0.8 / 0.5; steady-state — vials = level (ng/mL) × kg / 100; empiric 10 vials acute, 3–6 chronic | Indications: life-threatening arrhythmia, K⁺ >5 (acute), level >10–15. Avoid calcium (controversial) and cardioversion (use lowest energy). Treat hyperkalemia after Fab. |
| Local anesthetics (LAST) | 20% lipid emulsion 1.5 mL/kg bolus (100 mL if >70 kg), then 0.25 mL/kg/min; repeat bolus ×2; max ~12 mL/kg | Benzodiazepines for seizures; reduce epinephrine to ≤1 mcg/kg; avoid lidocaine, procainamide, vasopressin, CCBs, β-blockers. Prolonged CPR/ECMO. |
| Cyanide | Hydroxocobalamin 5 g IV over 15 min (repeat once) ± sodium thiosulfate 12.5 g IV | Smoke inhalation + lactate >8–10 + coma. Avoid nitrites if concurrent CO poisoning. Red urine/skin, interferes with colorimetric labs and dialysis sensors. |
| Carbon monoxide | 100% O₂ via non-rebreather/ETT; hyperbaric O₂ (2.5–3 ATA) for COHb >25%, LOC, neuro deficit, pregnancy with COHb >15–20%, myocardial ischemia | Pulse oximetry falsely normal; use co-oximetry. Half-life: 4–5 h room air, ~60–90 min on 100% O₂, ~20–30 min HBO. |
| Methemoglobinemia | Methylene blue 1–2 mg/kg IV over 5 min; repeat in 1 h if MetHb >30% or symptomatic | Causes: dapsone, benzocaine/lidocaine, nitrates, nitric oxide. SpO₂ ~85% regardless; chocolate-brown blood. Ineffective/harmful in G6PD deficiency — exchange transfusion. Serotonin syndrome with serotonergic drugs. |
| Toxic alcohols (methanol, ethylene glycol) | Fomepizole 15 mg/kg IV load, then 10 mg/kg q12 h × 4, then 15 mg/kg q12 h (q4 h during dialysis); hemodialysis (EXTRIP) for coma/seizures, visual deficits (methanol) or AKI (EG), anion gap >27 or pH ≤7.15–7.25, or high levels despite fomepizole (methanol >70 mg/dL; EG >50 mmol/L ≈ 300 mg/dL or osmolal gap >50) — the old "level >50 mg/dL" rule predates fomepizole; folate (methanol) or thiamine/pyridoxine (EG) | Anion gap + osmolar gap (>10). Ethanol infusion if fomepizole unavailable (target 100–150 mg/dL). |
| Organophosphates / nerve agents | Atropine 2–5 mg IV, doubling q3–5 min until secretions dry (not pupils); infusion 10–20% of loading dose/h · Pralidoxime 1–2 g IV over 15–30 min, then 500 mg/h · Benzodiazepines for seizures | SLUDGE/DUMBELS; bradycardia, bronchorrhea is the killer. Decontaminate — protect staff. Avoid succinylcholine (prolonged block). |
| Sulfonylureas | Dextrose then octreotide 50–100 mcg SC q6–8 h × 24 h | Octreotide suppresses insulin release; observe 24 h after last dose. Avoid prophylactic dextrose infusions alone (stimulate more insulin). |
| Iron | Deferoxamine 15 mg/kg/h IV (up to 35 mg/kg/h; max 6–8 g/day) for level >500 mcg/dL or shock/acidosis | Whole-bowel irrigation for radiopaque pills; "vin rosé" urine confirms chelation. Hypotension with rapid infusion; ARDS with prolonged use >24 h. |
| Serotonin syndrome | Stop agents; benzodiazepines; cyproheptadine 12 mg PO then 2 mg q2 h (max 32 mg/day); cooling; paralysis/intubation if T >41 °C | Hyperreflexia/clonus (lower > upper), mydriasis, diarrhea; onset <24 h. Linezolid, fentanyl, methylene blue, ondansetron, tramadol are common ICU culprits. |
| Neuroleptic malignant syndrome | Stop antipsychotic/restart dopamine agonist; bromocriptine 2.5–5 mg PO q8 h; dantrolene 1–2.5 mg/kg IV; benzodiazepines; cooling | "Lead-pipe" rigidity, hyporeflexia, bradykinesia; onset days–weeks; CK markedly elevated. Metoclopramide/haloperidol/abrupt levodopa withdrawal. |
| Anaphylaxis | Epinephrine 0.3–0.5 mg IM (anterolateral thigh) q5–15 min; refractory: 1–10 mcg/min IV infusion; crystalloid 1–2 L; H1/H2 blockers and steroids are adjuncts only; glucagon 1–5 mg IV if β-blocked | Delay in epinephrine is the main cause of death. Observe 4–24 h for biphasic reaction. Sugammadex, rocuronium, cefazolin, chlorhexidine common perioperative triggers. |
| Hyperthermia (heat stroke / MH / NMS) | Evaporative/immersion cooling to <39 °C within 30 min; dantrolene only for MH (2.5 mg/kg); benzodiazepines for shivering/agitation; avoid antipyretics | Antipyretics don't work for non-pyrogenic hyperthermia. Watch for rhabdomyolysis, DIC, liver injury. |
| Anticholinergic delirium | Physostigmine 0.5–1 mg IV over 5 min, repeat q10 min to 2 mg; benzodiazepines | Only for pure antimuscarinic delirium with normal QRS; atropine at bedside (cholinergic crisis). Contraindicated: QRS >100 ms, TCA, asthma, bowel obstruction. |
| Sympathomimetics (cocaine, amphetamines) | Benzodiazepines (diazepam 5–10 mg IV q5–10 min, no ceiling); cooling; nitroglycerin/phentolamine 1–5 mg for hypertension; NaHCO₃ for wide QRS; CCB for coronary spasm | Avoid β-blockers in acute cocaine toxicity (unopposed α). Hyperthermia is the killer — cool to <39 °C in 30 min. Body packers: surgery if symptomatic (cocaine); WBI if asymptomatic. |
| Isoniazid (and hydrazines, Gyromitra) | Pyridoxine 1 g per gram INH ingested (5 g IV empiric), repeat once; benzodiazepines | GABA depletion → seizures refractory to conventional agents; profound lactic acidosis resolves with seizure control. Phenytoin ineffective. Dialyzable. |
| Valproate | L-carnitine 100 mg/kg IV (max 6 g), then 15 mg/kg q4 h; hemodialysis for level >1,300 mg/L, cerebral edema, or shock (suggested >900 or coma) | Hyperammonemia without transaminitis, cerebral edema, pancreatitis, hypocalcemia, marrow suppression. Delayed peak with DR/ER forms. |
| Lithium | No antidote: isotonic saline; hemodialysis (EXTRIP) if level >4 with impaired kidney function, decreased LOC/seizures/dysrhythmia (any level), or level >5/confusion; recheck 6 h post-dialysis (rebound); WBI for sustained-release | Chronic toxicity is neurotoxic at lower levels (1.5–2.5). Not adsorbed by charcoal. Nephrogenic DI (amiloride helps), hypernatremia during saline loading. Precipitants: NSAIDs, ACEi/ARB, thiazides, dehydration. SILENT = persistent cerebellar injury. |
| Metformin-associated lactic acidosis | Hemodialysis (bicarbonate buffer) for lactate >20, pH ≤7.0, shock, decreased LOC, or failure of standard care; bicarbonate as a bridge | Vasopressor-refractory shock improves with correction of pH. Acute overdose: lactate rises over 6–12 h. No hypoglycemia (unlike sulfonylureas). |
| Theophylline / caffeine | MDAC; benzodiazepines/barbiturates for seizures; esmolol for SVT; hemodialysis for seizures, dysrhythmia, shock, level >100 mg/L (acute) or >60 (chronic) | Hypokalemia (β₂ shift — replace cautiously), hyperglycemia, vomiting. Chronic toxicity (CYP1A2 inhibitors: ciprofloxacin, macrolides) is dangerous at lower levels. Phenytoin ineffective. |
| Carbamazepine / phenobarbital | MDAC (both); urinary alkalinization (phenobarbital); hemodialysis (EXTRIP) for refractory seizures, life-threatening dysrhythmia, or prolonged coma/ventilator dependence | Carbamazepine: anticholinergic, sodium-channel (QRS), delayed absorption (bezoar), fluctuating course. Phenobarbital: prolonged coma, hypotension, hypothermia. |
| Bupropion | Benzodiazepines for seizures (delayed up to 24 h with XL); NaHCO₃ for QRS widening; lipid emulsion/ECMO for cardiovascular collapse | Observe ≥24 h after XL ingestion. Flumazenil and physostigmine lower the seizure threshold. |
| Chloroquine / hydroxychloroquine | Early intubation; diazepam 2 mg/kg over 30 min then 1–2 mg/kg/day; epinephrine infusion; NaHCO₃ for QRS; cautious K⁺ replacement | Rapid cardiovascular collapse and hypokalemia from intracellular shift (aggressive replacement → rebound hyperkalemia). Not dialyzable. |
| Clonidine / imidazolines | Naloxone 2–10 mg IV (inconsistent); atropine; fluids/vasopressors; supportive | Opioid-like toxidrome (miosis, bradycardia, CNS depression) with transient early hypertension. Children: eye/nasal drops, patches. |
| Loperamide (high dose) | NaHCO₃ for wide QRS; magnesium/isoproterenol/pacing for torsades; naloxone for CNS depression | Sodium- and hERG-channel blockade; abused for opioid withdrawal. Not dialyzable. |
| Hydrofluoric acid | Topical 2.5% calcium gluconate gel; intra-arterial calcium gluconate 10 mL 10% in 40 mL over 4 h (digits); IV calcium/magnesium guided by ionized levels; nebulized 2.5% Ca gluconate for inhalation; telemetry | Systemic hypocalcemia/hypomagnesemia/hyperkalemia → fatal dysrhythmia even with small concentrated exposures (>5% BSA, or any inhalation/ingestion → ICU). Never infiltrate calcium chloride. Pain out of proportion. |
| Caustics (alkali/acid) | No emesis, charcoal, neutralization, or blind NG; PPI; endoscopy at 12–24 h (not after 48 h); surgery for perforation; button battery in esophagus → remove within 2 h | Alkali: liquefactive necrosis (esophagus); acid: coagulative (stomach). Steroids do not prevent strictures. Zargar grade 2b–3 → stricture; dilation after 3 weeks. |
| Hydrocarbons | No charcoal/lavage; observe 6 h with CXR; supportive; halogenated agents → esmolol for dysrhythmias, avoid catecholamines | Aspiration pneumonitis (low viscosity); myocardial sensitization ("sudden sniffing death"); no prophylactic antibiotics/steroids. |
| Colchicine | Charcoal early; supportive; G-CSF for neutropenia; mechanical support; no antidote, not dialyzable | >0.5 mg/kg often lethal. Triphasic: GI (0–24 h) → multiorgan failure/arrhythmia/marrow aplasia (24–72 h) → recovery/alopecia. Deceptive early improvement. |
| Amatoxin mushrooms (Amanita) | MDAC; aggressive fluids; silibinin 5 mg/kg IV then 20 mg/kg/day (or penicillin G 300,000–1,000,000 U/kg/day); NAC; early transplant-center referral | Delayed GI onset 6–24 h (early onset <6 h suggests benign species), latent recovery, hepatic failure day 2–4. Transplant criteria similar to non-APAP ALF. |
| Crotalid (pit viper) envenomation | CroFab 4–6 vials (8–12 if severe), repeat until initial control, then 2 vials q6 h × 3; or Anavip 10 vials, repeat 10 as needed; elevation; serial limb measurements and labs (plt, fibrinogen, INR) q6 h | Antivenom treats swelling, coagulopathy, and compartment-like pressures — fasciotomy only for objectively elevated pressures after adequate antivenom. No tourniquets, ice, incision, or prophylactic antibiotics. Blood products only for active bleeding. Late recurrent coagulopathy (CroFab) — recheck at 2–3 and 5–7 days. Dry bites ~25%. |
| Other envenomations | Coral snake: antivenom 3–5 vials for any suspected bite (delayed paralysis) · Black widow: opioids/benzodiazepines; Latrodectus antivenom 1 vial for severe refractory pain · Scorpion (Centruroides): Anascorp 3 vials · Brown recluse: supportive wound care | Coral snake symptoms may be delayed 12 h — observe 24 h. Calcium gluconate for black widow is no longer recommended. Dapsone for recluse bites lacks evidence. |
| Heavy metals | Lead (encephalopathy or >70 mcg/dL): dimercaprol 3–5 mg/kg IM q4 h + CaNa₂EDTA 1–1.5 g/m²/day started 4 h later; mild: succimer 10 mg/kg PO q8 h × 5 d then q12 h × 14 d · Arsenic: dimercaprol 3 mg/kg IM q4–6 h then succimer · Mercury (inorganic): dimercaprol or succimer (organic: succimer only) · Thallium/cesium: Prussian blue 3 g PO TID · Plutonium/americium: Ca-DTPA 1 g IV | Dimercaprol: peanut-oil vehicle (peanut allergy), hemolysis in G6PD deficiency, contraindicated with organic mercury and iron (redistributes to brain), accumulates in renal failure. EDTA alone in lead encephalopathy → cerebral edema (give BAL first). Arsenic: cholera-like GI, QT/torsades, garlic odor, Mees lines. |
| Hydrogen sulfide / sodium azide / phosphine | H₂S: 100% O₂, remove from source; sodium nitrite 300 mg IV (methemoglobin induction) if severe; HBO · Azide/phosphine: supportive only | "Knockdown" gas with rotten-egg odor (olfactory fatigue); pulmonary edema. Rescuers need SCBA. Hydroxocobalamin has some support for H₂S. |
| Methotrexate | Glucarpidase 50 U/kg IV (level >1 µmol/L with AKI, or delayed clearance); leucovorin 100–1,000 mg/m² q6 h (give ≥2 h apart from glucarpidase); urinary alkalinization; hemodialysis (high-flux) if glucarpidase unavailable | Renal failure from crystal deposition; mucositis, marrow suppression. Hold NSAIDs, PPIs, TMP-SMX, penicillins (impair clearance). |
| Insulin overdose | Dextrose 10–20% infusion titrated; octreotide is not indicated; monitor glucose q30–60 min for 24–72 h (depot effect with long-acting analogs) | Hypokalemia; consider surgical excision of massive SC depots rarely. Sulfonylureas: octreotide (see above). |
| Anticoagulant rodenticides (brodifacoum) | Bleeding: vitamin K 10 mg IV + 4F-PCC/FFP; then oral vitamin K 50–100 mg/day for weeks–months, titrated to INR | Half-life weeks–months; a single vitamin K dose gives only transient correction. Do not give prophylactic vitamin K with a normal INR (masks the ingestion); recheck INR at 48 h. |
| Heparin / LMWH excess | Protamine 1 mg per 100 U UFH given in the last 2–3 h (max 50 mg, slow IV); enoxaparin: 1 mg per 1 mg (within 8 h; ~60% reversal), 0.5 mg/mg if 8–12 h | Excess protamine is itself an anticoagulant; hypotension/anaphylaxis with rapid infusion (NPH insulin, fish allergy, vasectomy ↑ risk). Fondaparinux: no reversal (rFVIIa anecdotal). |
| Alcohol withdrawal / Wernicke | Symptom-triggered benzodiazepines (CIWA); refractory (>40 mg diazepam-equivalent/h): phenobarbital 10–15 mg/kg IV load (or 130–260 mg boluses), then propofol/intubation; dexmedetomidine/ketamine adjuncts only · Thiamine 500 mg IV q8 h × 3 days for suspected Wernicke (200 mg for prophylaxis) | Haloperidol lowers the seizure threshold. Give thiamine before or with glucose but never delay glucose for hypoglycemia. Withdrawal seizures at 6–48 h, DTs at 48–96 h. |
| Baclofen (intrathecal) withdrawal | Restore intrathecal delivery (pump interrogation, lumbar catheter/bolus); high-dose benzodiazepines; propofol; dantrolene/cyproheptadine adjuncts; oral baclofen is insufficient | Hyperthermia, rigidity, rhabdomyolysis, autonomic instability, seizures — mimics sepsis/NMS/MH/serotonin syndrome; fatal if missed. Overdose: supportive, dialysis in renal failure. |
| Propofol infusion syndrome | Stop propofol (do not just reduce); CRRT for acidosis/hyperkalemia; pacing/ECMO; alternative sedation | Risk >4 mg/kg/h (67 mcg/kg/min) for >48 h, catecholamines, steroids, low carbohydrate intake. Metabolic acidosis, rhabdomyolysis, hyperkalemia, hypertriglyceridemia, Brugada-pattern ECG → bradyasystole. |
| Radiation / nuclear | Potassium iodide 130 mg PO (radioiodine, within 4 h); Prussian blue 3 g TID (cesium/thallium); Ca-DTPA 1 g IV then Zn-DTPA (plutonium, americium, curium); G-CSF for marrow syndrome | Absolute lymphocyte count at 48 h predicts dose. Decontaminate (remove clothing = 90%). Time to emesis <1 h suggests >4 Gy. |
| Source: Goldfrank's Toxicologic Emergencies, 11th ed.; EXTRIP Workgroup recommendations (lithium, salicylate, metformin, toxic alcohols, valproate, carbamazepine, phenobarbital, theophylline, acetaminophen, digoxin, TCAs, β-blockers); AACT/EAPCCT position statements on charcoal, multiple-dose charcoal, and whole-bowel irrigation; ACMT position statements (high-dose insulin, lipid emulsion); Unified Treatment Algorithm for crotaline snakebite (Lavonas 2011); ASRA LAST Checklist 2020; Dart et al. Acetaminophen Poisoning Consensus (JAMA Netw Open 2023); AHA 2025 special circumstances of resuscitation; Lexicomp. | ||
Adult dosing for study purposes only. Confirm against institutional protocols, pharmacy, and current package inserts.
Score: 0 / 0
Questions are original study items written to match the ABS Surgical Critical Care exam's format (clinical vignettes, single best answer, calculations, management judgment); they are not actual exam content, which is confidential. The Expert level uses longer multi-step vignettes whose distractors are each correct for a slightly different scenario — expect to read the explanation even when you are right. Explanations cite the trial or guideline they draw on.
Sources & references
Dosing tables and question explanations are drawn from the following guidelines, landmark trials, and references (most recent editions as of 2026).
Guidelines
- Evans L, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021;49:e1063.
- Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2026. Crit Care Med / Intensive Care Med 2026.
- Devlin JW, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS). Crit Care Med 2018;46:e825.
- Lewis K, et al. A Focused Update to the Clinical Practice Guidelines for the Prevention and Management of Pain, Anxiety, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med 2025.
- Murray MJ, et al. Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient. Crit Care Med 2016;44:2079.
- Kalil AC, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 IDSA/ATS Guidelines. Clin Infect Dis 2016;63:e61.
- Pappas PG, et al. IDSA Clinical Practice Guideline for the Management of Candidiasis: 2016 Update. Clin Infect Dis 2016;62:e1.
- Johnson S, et al. IDSA/SHEA Clinical Practice Guideline: 2021 Focused Update on Management of Clostridioides difficile Infection in Adults. Clin Infect Dis 2021;73:e1029.
- Mazuski JE, et al. Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect 2017;18:1.
- Rybak MJ, et al. Therapeutic Monitoring of Vancomycin: ASHP/IDSA/PIDS/SIDP Consensus Guideline 2020. Am J Health-Syst Pharm 2020;77:835.
- Panchal AR, et al. 2020 AHA Guidelines for CPR and Emergency Cardiovascular Care — Adult Basic and Advanced Life Support. Circulation 2020;142:S366.
- Perman SM, et al. 2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support. Circulation 2024;149:e254.
- 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (Part 9: Adult Advanced Life Support; Part 10: Special Circumstances; Part 11: Post–Cardiac Arrest Care). Circulation 2025.
- Nolan JP, et al. European Resuscitation Council and ESICM Guidelines 2021: Post-resuscitation Care. Intensive Care Med 2021;47:369.
- Peberdy MA, et al. Cardiopulmonary Resuscitation in Adults and Children With Mechanical Circulatory Support: AHA Scientific Statement. Circulation 2017;135:e1115.
- Society of Thoracic Surgeons Task Force on Resuscitation After Cardiac Surgery. Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery. Ann Thorac Surg 2017;103:1005.
- Seamon MJ, et al. An Evidence-Based Approach to Patient Selection for Emergency Department Thoracotomy: EAST Practice Management Guideline. J Trauma Acute Care Surg 2015;79:159.
- EXTRIP Workgroup recommendations on extracorporeal treatment for poisoning (lithium, salicylates, metformin, toxic alcohols, valproate, carbamazepine, phenobarbital, theophylline, acetaminophen, digoxin, β-blockers, TCAs), 2014–2021. extrip-workgroup.org
- American Academy of Clinical Toxicology / EAPCCT. Position papers: single-dose activated charcoal (2005), multi-dose activated charcoal (1999), whole bowel irrigation (2015 update). Clin Toxicol.
- Lavonas EJ, et al. Unified treatment algorithm for the management of crotaline snakebite in the United States. BMC Emerg Med 2011;11:2.
- St-Onge M, et al. Experts consensus recommendations for the management of calcium channel blocker poisoning in adults. Crit Care Med 2017;45:e306.
- Fishman JA, et al. American Society of Transplantation Infectious Diseases Community of Practice Guidelines, 3rd/4th ed. Clin Transplant 2019;33(9) (CMV, Pneumocystis, fungal, BK, EBV/PTLD, Nocardia guidelines).
- KDIGO. Clinical Practice Guideline for the Care of Kidney Transplant Recipients. Am J Transplant 2009;9(Suppl 3):S1.
- Kotloff RM, et al. Management of the Potential Organ Donor in the ICU: SCCM/ACCP/AOPO Consensus Statement. Crit Care Med 2015;43:1291.
- Lucey MR, et al. Long-Term Management of the Successful Adult Liver Transplant: AASLD/AST Practice Guideline. Liver Transpl 2013;19:3.
- Costanzo MR, et al. ISHLT Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2010;29:914; Snell GI, et al. ISHLT Consensus on Primary Graft Dysfunction. 2017.
- Carney N, et al. Guidelines for the Management of Severe Traumatic Brain Injury, 4th ed. Brain Trauma Foundation, Neurosurgery 2017;80:6.
- Greenberg SM, et al. 2022 AHA/ASA Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage. Stroke 2022;53:e282.
- 2026 AHA/ASA Guideline for the Early Management of Patients With Acute Ischemic Stroke. Stroke 2026.
- Hoh BL, et al. 2023 AHA/ASA Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage. Stroke 2023;54:e314.
- Brophy GM, et al. Guidelines for the Evaluation and Management of Status Epilepticus. Neurocrit Care 2012;17:3.
- Tomaselli GF, et al. 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants. J Am Coll Cardiol 2020;76:594.
- Cuker A, et al. American Society of Hematology 2018 Guidelines for Management of VTE: Heparin-Induced Thrombocytopenia. Blood Adv 2018;2:3360.
- Yorkgitis BK, et al. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma Clinical Protocol for VTE Prophylaxis in Trauma. J Trauma Acute Care Surg 2022;92:597.
- McClave SA, et al. ASPEN/SCCM Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient (2016) and Compher C, et al. 2022 update. JPEN 2022;46:12.
- KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012;2:1.
- Verbalis JG, et al. Diagnosis, Evaluation, and Treatment of Hyponatremia: Expert Panel Recommendations. Am J Med 2013;126:S1.
- Umpierrez GE, et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report (ADA/EASD/JBDS/AACE/DTS). Diabetes Care 2024;47:1257.
- Dart RC, et al. Management of Acetaminophen Poisoning in the US and Canada: A Consensus Statement. JAMA Netw Open 2023;6:e2327739.
- U.S. FDA / AstraZeneca. Withdrawal of Andexxa (andexanet alfa) from the U.S. market, December 2025 (ANNEXA-I thrombotic events). AABB news, 2025
- American Burn Association. Advanced Burn Life Support Course Provider Manual, 2018 update (consensus formula 2 mL/kg/%TBSA).
- American College of Surgeons Committee on Trauma. ATLS: Advanced Trauma Life Support, 10th ed., 2018.
- American College of Surgeons. Statement on Advance Directives by Patients: "Do Not Resuscitate" in the Operating Room (required reconsideration), 2014.
- Neal JM, et al. ASRA Practice Advisory on Local Anesthetic Systemic Toxicity: 2020 Checklist. Reg Anesth Pain Med 2021;46:81.
Landmark trials cited
- ARDSNet ARMA — NEJM 2000 (6 mL/kg)
- PROSEVA — NEJM 2013 (proning)
- ACURASYS — NEJM 2010; ROSE — NEJM 2019 (NMB in ARDS)
- OSCILLATE — NEJM 2013 (HFOV harm)
- FLORALI — NEJM 2015 (HFNC)
- ABC trial — Lancet 2008 (SAT/SBT)
- TracMan — JAMA 2013 (tracheostomy timing)
- SOAP II — NEJM 2010 (dopamine vs NE)
- VASST — NEJM 2008; ATHOS-3 — NEJM 2017
- ADRENAL & APROCCHSS — NEJM 2018 (steroids)
- NICE-SUGAR — NEJM 2009
- PROPPR — JAMA 2015; CRASH-2 — Lancet 2010; CRASH-3 — Lancet 2019
- TRICC — NEJM 1999; TRISS — NEJM 2014; MINT — NEJM 2023
- MENDS — JAMA 2007; SEDCOM — JAMA 2009; MIND-USA — NEJM 2018
- STARRT-AKI — NEJM 2020; BICAR-ICU — Lancet 2018; PRESERVE — NEJM 2018
- DOSE — NEJM 2011 (diuretics)
- EPaNIC — NEJM 2011; CALORIES — NEJM 2014; EDEN — JAMA 2012
- STOP-IT — NEJM 2015 (abx duration IAI)
- SUP-ICU — NEJM 2018
- TTM — NEJM 2013; TTM2 — NEJM 2021
- ALPS — NEJM 2016 (amiodarone vs lidocaine); PARAMEDIC2 — NEJM 2018 (epinephrine)
- DOSE-VF — NEJM 2022 (double sequential defibrillation)
- PART — JAMA 2018; AIRWAYS-2 — JAMA 2018 (airway in arrest)
- ARREST — Lancet 2020; Prague OHCA — JAMA 2022 (ECPR)
- COACT — NEJM 2019; TOMAHAWK — NEJM 2021 (angiography without STEMI)
- VAM-IHCA — JAMA 2021 (vasopressin + methylprednisolone)
- PEITHO — NEJM 2014 (submassive PE)
- PANTER — NEJM 2010; POINTER — NEJM 2021 (infected necrosis)
- MERINO — JAMA 2018 (ESBL bacteremia)
- EPVent-2 — JAMA 2019 (esophageal-pressure PEEP)
- ESETT — NEJM 2019; RAMPART — NEJM 2012
- INTERACT-2 — NEJM 2013; ATACH-2 — NEJM 2016; PATCH — Lancet 2016
- RESCUEicp — NEJM 2016; CRASH — Lancet 2004 (steroids in TBI)
- DEXA-ARDS — Lancet Respir Med 2020
- CONFIRM — NEJM 2021 (terlipressin)
- WATERFALL — NEJM 2022 (pancreatitis fluids)
- Keystone ICU Project — NEJM 2006 (CLABSI bundle)
Reference texts & drug references
- Marino PL. Marino's The ICU Book, 4th ed. Wolters Kluwer, 2014.
- Gilbert DN, et al. The Sanford Guide to Antimicrobial Therapy, 2025.
- Nelson LS, et al. Goldfrank's Toxicologic Emergencies, 11th ed. McGraw-Hill, 2019.
- Danovitch GM. Handbook of Kidney Transplantation, 6th ed. Wolters Kluwer, 2017.
- Lexicomp / UpToDate drug monographs and FDA package inserts (accessed 2026).
- Surgical Critical Care Evidence-Based Medicine Guidelines, surgicalcriticalcare.net (Orlando Regional Medical Center).
- American Board of Surgery. Surgical Critical Care Certifying Examination Content Outline. absurgery.org