NTG IV and compatability

  1. Hi everyone. I have a question about Nitro IV. In my Davis' Drug guide it says that the manufacturers don't recomend mixing or adding anything to it or running it with anything else. I have also heard other RNs saying that nothing gets along with NTG. But the Davis' also lists some Y-site compatabilities (amiodarone, dilitiazem, dopamine, epi, famotidine, fentanyl, lasix, mso4, theo, propofol, and many others). I'm confused, what does everyone out there do??? Thanks!
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  2. 20 Comments

  3. by   rollingstone
    Heparin gtt and Nitro gtt are compatible. Morphine IVP can be given too with Nitro infusing. If you're confused after consulting an up-to-date drug reference give your friendly pharmacist a buzz. They're a great resource.
  4. by   gwenith
    Bottom line - don't mix anything if you have any options. it's a GOOD rule. But when you gotta then you gotta.

    One of the things that you have to consider is maintaining a steady flow of the drug.

    Found this

    http://www.cs.nsw.gov.au/rpa/neonatal/html/meds/gtn.htm

    http://members.ozemail.com.au/~james.../drugs/122.htm
  5. by   traumaRUs
    In our hospital the official policy is NTG runs by itself. However, (there are always caveats) if no further venous access is available, then we run NTG and Heparin together. We do it fairly frequently due to the fast door to cath lab that we do.
  6. by   NYCRN16
    If my patient is getting a nitro gtt and heparin gtt, I will start another line in order to give them. This is the easiest solution in order to give them. Interestingly enough, a lot of my patients who come in for GI bleeders also are having MI's, and a 3rd line is started to accomidate the protonix gtt!
  7. by   Pete495
    Nitro actually is compatible with many things, such as Dopa, dobut., epi, vasopressin, primacor, cardizem, heparin, etc. check your compatibility chart, or drug book. course, usually this is when we're running things through a central line. If I'm running it peripherally, I always have another site mostly because you may need to give something else IV, esp. in a hurry since NITRO is a cardiac drug. It's just safe to have another site. Our hospital policy says we must always have an available site in critical care.
  8. by   newfloridaRN
    On all of our Acute MI patients, we usually run NTG with Saline and Heparin....If ordered that is. They are compatible.
  9. by   GDog7NYC
    When a patient comes into the ED and you suspect ACS related chest pain, it's usually a good idea to start at LEAST 2 peripheral lines immediately. If you have the opportunity for a third, then go for it! That would solve your Nitro/Heparin dilemma (but Nitro and Heparin are compatible for at least 24 hours so by the end of that time frame, your patient should be out of the ED). The other thing is, if you have to push IV Lopressor or Morphine or start GP IIb-IIIa agents such as Integrilin or Reopro, or other drugs which will require a dedicated line, then you've got that base covered as well.
    Last edit by GDog7NYC on May 12, '04 : Reason: spell check
  10. by   veetach
    If Nitro is compatible with the drug, I run them together. Especially Heparin.
  11. by   zambezi
    We run ntg with other compatible drugs all the time. As pete stated, I try to keep my vasoactives together so if I have to flush fast for whatever reason, I have an extra line to do it in. I try to keep meds seperated as much as possible but I mix and match per compatibility when necessary. I agree with what pete mentioned about have and extra site. Sometimes that is not always possible but I always try to have a site when I am running something that I can interrupt is necessary.
  12. by   rnmaven
    Quote from jaimealmostRN
    Hi everyone. I have a question about Nitro IV. In my Davis' Drug guide it says that the manufacturers don't recomend mixing or adding anything to it or running it with anything else. I have also heard other RNs saying that nothing gets along with NTG. But the Davis' also lists some Y-site compatabilities (amiodarone, dilitiazem, dopamine, epi, famotidine, fentanyl, lasix, mso4, theo, propofol, and many others). I'm confused, what does everyone out there do??? Thanks!
    Dear JaimealmostRN,

    I wish I still had a hardcopy of the article on IV heparin and NTG but it's been alot of years since I read the article in the AACN journal for critical care. As I remember it, the findings were that if you run NTG and Heparin together (at the Y-site) there is a problem with obtaining accurate PTT readings. Therefore, you will see that most policies require a separate line for NTG infusions.

    Now, in response to some of the other responses I read on this discussion, let me say that some of your best sources for this information comes from the drug manufacturers. I worked for Abbott Hospital products and we did alot of drug studies with various pharmacy schools on this topic because we sold infusion pumps that utilized cassette technology where drugs "mixed" in the cassette during infusion of multiple drugs.

    I also was a manger for INTEGRILIN and I can tell you that the company invested money in documenting compatibility of Heparin and INTEGRILIN as these two drugs were commonly infused together at the Y-site.

    Now to clarify some of the confusion regarding drug compatibility data.....You will see information regarding compatibility in solution......in other words when drugs are mixed in the same container and you will see data on compatibility at the Y-site. When you look at the information comparing these types of drug compatibilities it all comes down to the following concept: How long do the drugs "mix together" in the same container or line. If you run two drugs together at the Y-site, depending on their respective infusion rates and the priming volume of the IV tubing, these drugs may actually mix (or touch each other) for varying lengths of time. Compatiblity be it physical or chemical is related to drug-mixing time.

    The long and short of it is this........if your hospital has a good Pharm.D on staff, they can research this information for you. If you want to work on changing policy, you can contact drug companies drug information departments and they will be happy to supply you with the information you require.

    Hope this clarifies your question!

  13. by   rnmaven
    Quote from jaimealmostRN
    Hi everyone. I have a question about Nitro IV. In my Davis' Drug guide it says that the manufacturers don't recomend mixing or adding anything to it or running it with anything else. I have also heard other RNs saying that nothing gets along with NTG. But the Davis' also lists some Y-site compatabilities (amiodarone, dilitiazem, dopamine, epi, famotidine, fentanyl, lasix, mso4, theo, propofol, and many others). I'm confused, what does everyone out there do??? Thanks!
    Just a few more thoughts on drug compatibility. One of the many things I see working in critical care is that nurses seem to think that they can Y-together drugs via an extension set that is attached to the patient's IV angiocath. I see them running one drug into one pigtail of the extension set and another drug into another pigtail......yet those two drugs are not compatible. When I bring this to their attention they say that they aren't mixing for very long so it's OK.

    Now, if you're working in a small ICU where you just can't get a central line and the 90-some year old patient just doesn't have a vein to be had.....I guess you gotta do what you gotta do. But I'm afraid that many nurses just aren't thinking when they do this kind of set up.

    I had another critical care article where they did radiographic studies of simultaneous injections of Dilantin and Calcium via two separate ports of a triple lumen catheter. They documented via x-Ray the "white cloud" of drug precipitate that entered the bloodstream when these two KNOWN incompatible drugs were injected. The reason this occurred is because the two ports of the TLC are close together and when the drugs exit into the bloodstream they "touch" and created the physical incompatibility.

    So remember.......just because you don't see the incompatibility don't think it's not happening!
  14. by   RNCENCCRNNREMTP
    Quote from rnmaven
    Dear JaimealmostRN,

    I wish I still had a hardcopy of the article on IV heparin and NTG but it's been alot of years since I read the article in the AACN journal for critical care. As I remember it, the findings were that if you run NTG and Heparin together (at the Y-site) there is a problem with obtaining accurate PTT readings. Therefore, you will see that most policies require a separate line for NTG infusions.
    Here is some info on nitro and heparin:

    Andrew Bowman

    "Lack of in vitro interaction between heparin and NTG"
    American Journal of Clinical Pathology
    March 1996
    "No direct effect of NTG on the anticoagulant effect of heparin was observed as measured by aPTT"

    "The effect of simultaneous IV administration of NTG and heparin on PTT"
    Military Medicine September 1995
    "This study indicates no significant difference in PTT in subjects receiving these infusions via separate or SAME IV sites"

    "Interaction of IV heparin and organic nitrates in acute ischemic syndromes"
    AJC October 1995
    "The heparin dose did not show a significant correlation to the dose of IV NTG"

    "A clinical and in vitro study on the possible interaction of IV nitrates with heparin anticoagulation"
    Clinical Cardiology December 1994
    "Nitrates had no effect on heparin activity in vitro"

    "NTG induced heparin resistance"
    Military Medicine August 1994
    "Results show no inhibition of heparin anticoagulation by IV NTG at clinically relevant doses"

    "Effects of IV NTG on heparin dosage requirements"
    AJC August 1993
    "Clinically significant heparin resistance was not found"

    "Assessment of the drug interaction between IV NTG and heparin"
    Annals of Pharmacotherapy December 1992
    "Study demonstrates a clinically insignificant interaction between NTG and heparin at NTG doses commonly used in patients"

    "Absence of NTG induced heparin resistance in healthy volunteers"
    European Heart Journal
    March 1992
    "A previously described NTG induced heparin resistance could not be verified by in vitro experiments or in a randomized, double-blind, crossover trial in healthy volunteers"

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