What is the recommended IV furosemide (Lasix) dosing protocol for an adult with pulmonary edema, especially if the patient is elderly, has moderate renal impairment, or is hypotensive?

How to Administer IV Furosemide for Pulmonary Edema

For acute pulmonary edema, start with furosemide 40 mg IV push over 1-2 minutes combined with high-dose IV nitroglycerin, but only if systolic blood pressure is ≥90-100 mmHg—never give furosemide to hypotensive patients as it will worsen shock. 1, 2

Critical Pre-Administration Requirements

Before administering any furosemide, verify the following absolute prerequisites:

• Systolic blood pressure must be ≥90-100 mmHg without circulatory support 1, 3
• Exclude severe hyponatremia (serum sodium <120-125 mmol/L) 1, 3
• Exclude marked hypovolemia (assess skin turgor, orthostatic vital signs) 1, 3
• Exclude anuria (complete absence of urine output) 1, 3

Common pitfall: Giving furosemide to hypotensive patients expecting it to improve hemodynamics—it causes further volume depletion, worsens tissue perfusion, and can precipitate cardiogenic shock. 1 If blood pressure is low, provide circulatory support with inotropes or vasopressors first. 1

Initial Dosing Protocol

Standard Initial Dose

• Administer 40 mg IV push slowly over 1-2 minutes for acute pulmonary edema 1, 2
• For patients already taking oral furosemide chronically, use at least their equivalent oral dose IV (e.g., if taking 80 mg PO daily, give 80 mg IV) 1, 3
• For diuretic-naïve patients or those on low doses, start with 20-40 mg IV 1, 3, 2

Concurrent Therapy (Critical)

Furosemide should NOT be used as monotherapy in acute pulmonary edema. 1 The evidence strongly favors combination therapy:

• Start IV nitroglycerin immediately alongside furosemide and titrate to the highest hemodynamically tolerable dose 1
• High-dose nitrates with low-dose furosemide are superior to high-dose furosemide alone, reducing intubation rates (13% vs 40%, P<0.005) and myocardial infarction (17% vs 37%, P<0.05) 1
• Consider morphine 2.5-5 mg IV for severe dyspnea, restlessness, or anxiety 1, 3
• Apply non-invasive positive pressure ventilation (CPAP/BiPAP) if respiratory rate >20 breaths/min and SBP >85 mmHg 1, 3

Dose Escalation Algorithm

If urine output remains <0.5 mL/kg/hour after 2 hours, follow this escalation:

• Double the dose (e.g., 40 mg → 80 mg IV) given slowly over 1-2 minutes 1, 3, 2
• Maximum single bolus: 160-200 mg 3, 2
• Do not exceed 100 mg in the first 6 hours or 240 mg in the first 24 hours 1, 3
• Increase in 20 mg increments every 2 hours until adequate diuresis achieved 3

For Doses ≥250 mg

• Administer as continuous infusion over 4 hours (maximum rate 4 mg/min) to prevent ototoxicity 1, 3, 2
• Consider switching to continuous infusion at 5-10 mg/hour after initial bolus if requiring high total doses 1, 3

Special Populations

Elderly Patients

• Start with 20 mg IV and titrate more slowly 3
• Elderly patients have 2-3 fold longer furosemide half-life and increased risk of orthostatic hypotension 3
• Monitor supine and standing blood pressure frequently 3

Moderate Renal Impairment

• Higher initial doses required (40-80 mg IV) due to reduced tubular secretion and fewer functional nephrons 3
• Expect delayed and diminished diuretic response 3
• Do NOT use furosemide to treat acute kidney injury itself—only for managing volume overload that complicates AKI 3

Hypotensive Patients

• Furosemide is contraindicated if SBP <90 mmHg without circulatory support 1, 3
• Provide inotropic support (dobutamine) or vasopressors first, then cautiously add low-dose furosemide once blood pressure stabilizes 1
• Consider intra-aortic balloon pump in cardiogenic shock before diuretics 1

Essential Monitoring

Immediate (First 2 Hours)

• Place bladder catheter to monitor hourly urine output and rapidly assess response 1, 3
• Target urine output >0.5 mL/kg/hour 3
• Blood pressure every 15-30 minutes watching for hypotension 3

Within 6-24 Hours

• Electrolytes (sodium, potassium, magnesium) 1, 3
• Renal function (creatinine, BUN) 1, 3
• Daily weights at same time each day, targeting 0.5-1.0 kg loss per day 1, 3

Ongoing

• Electrolytes and renal function every 3-7 days during active diuresis 3
• Stop furosemide immediately if severe hyponatremia (<120-125 mmol/L), severe hypokalemia (<3 mmol/L), or anuria develops 1, 3

Managing Diuretic Resistance

If inadequate diuresis after 24-48 hours at standard doses:

• Add a second diuretic class rather than escalating furosemide beyond 160 mg/day: 1, 3
  • Hydrochlorothiazide 25 mg PO, OR
  • Spironolactone 25-50 mg PO, OR
  • Metolazone 2.5-5 mg PO
• Switch from intermittent boluses to continuous infusion (5-10 mg/hour) 1, 3
• Consider low-dose dopamine 2.5 μg/kg/min to enhance renal perfusion 3
• If maximal medical therapy fails, consider ultrafiltration 3

Critical Safety Warnings

Absolute Contraindications During Treatment

• Systolic BP <90 mmHg without circulatory support 1, 3
• Severe hyponatremia (sodium <120-125 mmol/L) 1, 3
• Anuria (complete absence of urine output) 1, 3
• Severe hypokalemia (<3 mmol/L) 3
• Marked hypovolemia 1, 3

Important Caveats

• Furosemide transiently worsens hemodynamics in the first 1-2 hours (increased systemic vascular resistance, increased LV filling pressures, decreased stroke volume) before diuresis improves them 1
• High-dose furosemide is associated with worsening renal function and increased mortality when used inappropriately 1
• Ototoxicity risk increases with doses >6 mg/kg/day or rapid IV push of high doses 3, 2
• Avoid concurrent aminoglycosides due to dramatically increased ototoxicity risk 3