What are the recommended sterile preparation concentrations and infusion dosing ranges for common continuous infusions (vasopressors/inotropes, sedatives, analgesics, antibiotics, insulin, electrolytes) in a typical adult intensive care unit?

ICU Drug Infusion Preparation and Dosing

Vasopressors and Inotropes

Norepinephrine is the first-line vasopressor for shock states, dosed at 0.2-1.0 μg/kg/min IV infusion, titrated to maintain MAP ≥65 mmHg. 1, 2

Standard Vasopressor/Inotrope Dosing Ranges

• Norepinephrine: 0.2-1.0 μg/kg/min IV infusion (first-line for septic shock and most hypotensive states) 1, 2
• Dopamine: 2-3 μg/kg/min (dopaminergic effects), 3-5 μg/kg/min (inotropic effects), >5 μg/kg/min (vasopressor effects) 1
• Dobutamine: 2-20 μg/kg/min IV infusion without loading dose (first-line inotrope for cardiogenic shock with low cardiac output) 1
• Epinephrine: 0.05-0.5 μg/kg/min IV infusion (reserved for persistent hypotension despite other agents) 1
• Vasopressin: 0.01-0.04 units/min for distributive shock with inadequate response to norepinephrine 1

Preparation Concentrations

• Dopamine: 400 mg in 500 mL D5W for hypotension refractory to volume replacement 3
• Titrate all vasopressors to the lowest effective dose to achieve adequate organ perfusion 1
• Continuous hemodynamic monitoring is essential during vasopressor infusions 3

Critical Monitoring Requirements

• ECG monitoring is required during all inotrope infusions due to arrhythmia risk 1
• Monitor for tachyarrhythmias, myocardial ischemia, and peripheral tissue ischemia 1

---

Sedatives and Analgesics

Minimize continuous sedation in mechanically ventilated ICU patients, targeting light sedation (RASS -2 to 0) rather than deep sedation to improve outcomes. 4, 3

Sedation Agent Selection and Dosing

• Propofol: First-line for short-term sedation (<24 hours); initiate at lowest possible dose with extremely slow titration in septic shock or hemodynamically unstable patients 4, 5
• Dexmedetomidine: First-line agent allowing lighter sedation levels and maintained arousability 4
• Lorazepam: Preferred for prolonged sedation (>24 hours) 5
• Midazolam: Preferred only for short-term (<24 hours) anxiety treatment 5
• Avoid benzodiazepines as first-line agents due to association with deeper sedation, increased delirium, and prolonged mechanical ventilation 4

Analgesic Dosing

• Morphine sulfate: Preferred analgesic for critically ill patients 5
• Fentanyl: Preferred for hemodynamically unstable patients or those with histamine release/morphine allergy 5
• Hydromorphone: Acceptable alternative to morphine 5

Sedation Management Protocol

• Target RASS -2 to +1 (light sedation) in mechanically ventilated sepsis patients 4
• Perform daily spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) in all mechanically ventilated patients meeting safety criteria 4
• Use nurse-directed sedation protocols incorporating RASS assessments 4
• Never extubate patients still requiring vasopressors (absolute contraindication) 4

Delirium Management

• Haloperidol: Preferred agent for delirium treatment in critically ill adults 5
• Monitor for delirium using validated tools (CAM-ICU) in conjunction with RASS scoring 4
• Avoid antipsychotics in patients at significant risk for torsades de pointes 3

---

Antibiotics

Administer β-lactam antibiotics (cefepime, piperacillin-tazobactam, meropenem, doripenem) by prolonged IV infusion over 3-4 hours for severe infections, especially with high MIC bacteria. 3

β-Lactam Antibiotic Administration

• Prolonged infusion (3-4 hours) of β-lactams reduces mortality (10.8% vs 16.8% with intermittent infusion, p=0.03) 3
• Target plasma concentrations above MIC for at least 70% of time; optimal target Cmin/MIC ratio of 4-6 3
• Continuous infusion recommended for carbapenems (meropenem, doripenem), ceftazidime, and piperacillin-tazobactam when risk of pharmacodynamic failure exists (deep infection sites, major pharmacokinetic changes, high MIC) 3

Vancomycin Administration

Administer vancomycin by continuous infusion after a loading dose of 35 mg/kg to rapidly achieve target concentration of approximately 20 mg/L, followed by continuous infusion of 35 mg/kg to maintain this level. 3

• Target steady-state concentration: 20 mg/L (can be higher for CNS, cardiac vegetations, or bone infections) 3
• Continuous infusion achieves target concentrations more rapidly than intermittent dosing 3
• Target AUC24h/MIC ratio >400 for pneumonia and MRSA bacteremia 3

Broad-Spectrum Coverage for Sepsis

• 100% of ICU patients: 1 g ceftriaxone per day 3
• 50% of ICU patients: 13.5 g piperacillin-tazobactam per day 3
• One course each of: anti-MRSA, broad-spectrum, atypical bacterial, and antiviral coverage 3

---

Insulin Infusion

Use protocolized insulin therapy when two consecutive blood glucose levels are >180 mg/dL, targeting upper blood glucose ≤180 mg/dL (NOT ≤110 mg/dL, as tight control increases harm). 2

• Avoid tight glycemic control (target ≤110 mg/dL) due to increased harm 2
• Target range: maintain blood glucose ≤180 mg/dL 2

---

Neuromuscular Blockade

Avoid neuromuscular blocking agents in septic patients without ARDS; for sepsis-induced ARDS with PaO2/FiO2 <150 mmHg, consider neuromuscular blockade for ≤48 hours maximum. 4

• Use intermittent boluses or continuous infusion with train-of-four monitoring 4
• Ensure adequate sedation and analgesia before initiating neuromuscular blockade 4
• Prolonged blockade risk exists in septic patients 4

---

Electrolyte Replacement

• Standard electrolyte replacement protocols should be established per ICU 3
• Monitor and replace as needed based on daily laboratory values 3

---

Critical Pitfalls to Avoid

• Do not use propofol for rapid sequence induction in refractory septic shock without aggressive hemodynamic support 4
• Never extubate patients requiring vasopressors 4
• Avoid excessive sedation that delays recognition of extubation readiness 4
• Do not target tight glycemic control (≤110 mg/dL) as this increases harm 2
• Avoid benzodiazepines as first-line sedatives due to delirium risk 4