Can Lasix (furosemide) and Nitroglycerin (NTG) infusion be given through the same single port cannula or Peripherally Inserted Central Catheter (PICC) line?

Can Lasix and NTG Infusion Be Given Through a Single Port Cannula or PICC Line?

Yes, Lasix (furosemide) and nitroglycerin (NTG) infusion can be administered through the same single-port cannula or PICC line, but they should NOT be mixed together in the same solution and require proper flushing between medications to prevent incompatibility. 1

Critical FDA Warning About NTG Administration

• Nitroglycerin should never be mixed with any other medication of any kind when prepared in 5% dextrose or sodium chloride 0.9%, according to FDA labeling 1
• Administration of nitroglycerin infusions through the same infusion set as other medications can result in drug interactions and incompatibilities 1

Safe Administration Protocol Through Single-Lumen Access

Sequential Administration (Preferred Method)

• Administer furosemide as an IV push/bolus first, flush the line thoroughly with compatible solution (normal saline), then start the NTG infusion 1, 2
• This sequential approach prevents direct mixing of the two medications in the same line 2, 3

If Multi-Lumen PICC Available (Optimal)

• Use separate lumens for each medication - dedicate one lumen to the NTG infusion and use another lumen for furosemide boluses 4
• Multi-lumen catheters allow simultaneous administration without risk of incompatibility, though single-lumen catheters are preferred when multiple ports are not essential 4

Evidence Supporting Combined Use

• Studies demonstrate that furosemide and nitroglycerin are commonly used together in acute heart failure management, with the combination showing improved respiratory outcomes compared to either agent alone 4
• Research shows that NTG can prevent the transient increase in pulmonary capillary wedge pressure (PCWP) that furosemide causes when given alone 4

Critical Technical Considerations

For NTG Infusion Specifically

• Use non-PVC tubing for NTG infusions - standard PVC tubing absorbs 40-80% of nitroglycerin, resulting in unpredictable dosing 1
• The FDA mandates that dosing instructions must be followed carefully when appropriate low-absorbing infusion sets are used, as published doses were based on PVC tubing with significant drug loss 1

For PICC Line Use

• Verify catheter tip position is in the lower third of the superior vena cava or upper right atrium before use 5, 6
• Ensure proper flushing protocols before and after each medication administration to maintain catheter patency 5
• Monitor for signs of catheter-related infection, though PICC-related bloodstream infections are relatively low compared to other central access devices 4, 5

Common Pitfalls to Avoid

• Never attempt to mix furosemide and NTG in the same syringe or bag - this violates FDA guidelines and creates incompatibility risk 1
• Do not use in-line IV filters with NTG infusions, as these absorb nitroglycerin and reduce delivered dose 1
• Avoid inadequate flushing between medications when using single-lumen access - this is the most common cause of incompatibility-related complications 2, 3
• Do not assume standard PVC tubing is acceptable for NTG - this results in massive underdosing 1

Practical Clinical Algorithm

If single-lumen peripheral IV or PICC:

1. Administer furosemide IV push (typically over 1-2 minutes)
2. Flush line with 10 mL normal saline
3. Start NTG infusion using non-PVC tubing
4. For subsequent furosemide doses: pause NTG, flush line, give furosemide, flush again, resume NTG 2, 3

If multi-lumen PICC (preferred for continuous therapy):

1. Dedicate one lumen exclusively to NTG infusion
2. Use separate lumen for furosemide boluses
3. No flushing between medications required 4

Hemodynamic Monitoring Considerations

• Be aware that furosemide initially causes transient hemodynamic worsening (increased heart rate, mean arterial pressure, and LV filling pressure) for 1-2 hours before diuretic effect 4
• NTG provides immediate venodilation that counteracts these adverse hemodynamic effects of furosemide 4
• Monitor blood pressure closely as both medications can cause hypotension, particularly when used together 1