Amiodarone and ACLS

Amiodarone and ACLS


Amiodarone is considered a class III antiarrhythmic agent and is used for various types tachyarrhythmias. Because of its associated toxicity and serious side-effects it should be used cautiously and care should be taken to ensure that cumulative doses are not exceeded.

Indications for ACLS

Amiodarone is an antiarrhythmic that is used to treat both supraventricular arrhythmias and ventricular arrhythmias.

The mechanism of action of amiodarone remains unknown, but within the framework of ACLS, amiodarone is used primarily to treat ventricular fibrillation and ventricular tachycardia that occurs during cardiac arrest and is unresponsive to shock delivery, CPR, and vasopressors.

Amiodarone should not be used in individuals with polymorphic VT as it associated with a prolonged QT interval which is made worse with antiarrhythmic drugs.

Amiodarone should only be used after defibrillation/cardioversion and first line drugs such as epinephrine and vasopressin have failed to convert VT/VF.

Route

Amiodarone can be administered by intravenous or intraosseous route.

Dosing

The maximum cumulative dose in a 24 hour period should not exceed 2.2 grams.

Within the VT/VF pulseless arrest algorithm, the dosing is as follows:
300mg IV/IO push → (if no conversion) 150 mg IV/IO push → (after conversion) Infusion #1 360 mg IV over 6 hours (1mg/min) → Infusion #2 540 mg IV over 18 hours (0.5mg/min)

For tachyarrhythmias other than life threatening, expert consultation should be considered before use.

For Tachycardia other than pulseless VT/VF, Amiodarone dosing is as follows: (see above note)
150 mg over 10 minutes → repeat as needed if VT recurs → maintenance infusion of 1mg/min for 6 hours

Amiodarone should only be diluted with D5W and given with an in-line filter.

Infusions exceeding 2 hours must be administered in glass or polyolefin bottles containing D5W.

Return to main ACLS Pharmacology page.

Comments

  1. Jenny says

    I am still confused as to the dilution. When taking my ACLS class we did not dilute the Amiodarone but just pushed the 300mg dose. However, now looking at my crash cart; the bottle says “must be diluted” (it is already reconstituted liquid form) Also, the drug book says for loading dose to dilute 150mg/100mL D5W.. but is this a hanging med vs. cardiac arrest push? thanks!

    • says

      If it is a cardiac emergency (pulseless VT/VF) you can give the amiodarone undiluted and IV push. (cardiac emergencies are an exception to the “must be diluted rule.”

      If the patient has stable or unstable tachycardia, they should be treated according to the algorithm and then amiodarone can be give diluted and hung as a loading dose infusion.

      Kind regards,
      Jeff

  2. David says

    In the context of a WCT which resembles VT the UK guidelines suggest giving amiodarone loading 300mg IV over 20-30 mins then a maintenance 900mg IV over 24 hours. Are you aware of why there is a difference between the two guidelines?

    Also should a patient present with stable VT (i.e with pulse) and is already on amiodarone orally how should the physician proceed? Do we simply omit the loading dose of amiodarone or switch to a different anti-arrythmic e.g. lidocaine?

    Thanks,
    David

    • says

      1st question reply: I am not aware of why there is a difference between the UK guidelines and the American Heart Association guidelines.
      2nd question reply: For the Pt. with stable VT and already on amiodarone, the best option would be to consult the cardiologist. The stable patient is better managed by the specialist in this type of situation.

      Kind regards,
      Jeff

    • says

      This is the only fluid in which amiodarone is stable. Amiodarone when mixed in other fluids can precipitate out into solid form. There are some new companies that have developed amiodarone that is stable with NS but I have not used this variety up until now.

      Kind regards,
      Jeff

      • Laura says

        There is data to support bolusing amiodarone undiluted during pulseless VT/VF. The initial concern with bolusing amiodarone undiluted was that it would cause hypotension and bradycardia, but with the newer formulation, this does not appear to be as much of an issue. Can you please confirm that dilution is required? I have worked at 3 different institutions, and none have diluted amiodarone in pulseless VT/VF.

      • says

        This was my mistake. I should have said “It should be diluted reconstituted in at least 10 ml of D5W for IV push use during cardiac arrest.”

        The vials of amiodarone that I have seen all require a reconstitution with 10 ml of D5W. Is that what you have encountered?

        Kind regards,
        Jeff

    • says

      Amiodarone when used for arrhythmias will always need a loading dose. Amiodarone when given with cardiac arrest is given as a rapid IV bolus. There is no loading dose when amiodarone is considered during cardiac arrest. It is simply a bolus dose.

      Kind regards,
      Jeff

  3. Mike Freauf says

    In regards to Amiodarone dilution for pediactric resus. Most services stipulate use of D5W for dilution. I have seen some services using D10W instead?? Any evidence why they are doing this when manufactor advises use of D5W??

    • says

      I do not know the rational for using D10W instead of D5W. I don’t think that it would be make much of a difference. You might ask the service or possibly the in-house pharmacy.

      Kind regards,
      Jeff

    • says

      AHA no longer recommends the prophylactic use of amiodarone in any situation. If there is any occurrence of an arrhythmia then you would be justified in starting an amiodarone infusion.
      I must say that AHA guidelines are simply guidelines. A physician can diverge from the guidelines if they feel that the situation warrants this. I know physicians who use amiodarone prophylactically, but there is no justification according to the clinical research at this time.

      Kind regards,
      Jeff

  4. janisemorris says

    Why must amio be delivered in a glass or polyolefin bottle past 2 hours? Is it because the chemical can break down a standard bag? (nursing student with very little experience or knowledge of this drug)

    • says

      This is because the amiodarone adheres to the PVC bags and it reduces that amount of amiodarone that is available in the bag.
      Over the past couple of years, there has been the development of “PVC friendly” amiodarone and there are now FDA approved forms of amiodarone that can be used in plastic bags. You will need to check the amiodarone package insert to determine whether you need to use the glass/polyolefin alternative.

      Kind regards,
      Jeff

  5. onkface says

    How fast should I push amio first and second dose, and if the patient does not convert, how often can I give additional dosing of 150mg

    • says

      When given in emergency situations, amiodarone should be pushed as rapidly as you can push the plunger down. After giving the amiodarone, make sure that you flush with 20ml of NS. The amiodarone can be given 300mg and then 150mg. A 3rd 150mg may be given if needed. By this time you will bu pushing 15 minutes and you will begin to question whether the code should be stopped.
      Kind regards,
      Jeff

  6. ekkeel says

    you do not go into the dosing of procainamide and sotalol. Is that because they are not considered for use by basic ACLS providers and are not on the test? I guess they could be part of the megacode and not the written exam? What is your experience? Thanks so much for this site. It has given me lots of info and much more confidence.

    • says

      You are correct. In the last 5 years, I have not seen these covered in any manner on the test or in a megacode situation. In my experience, these two medications are rarely used, and in an attempt to deemphasize the use of medications the AHA has not included much information about them.

      Kind regards,
      Jeff

  7. says

    Can you please cite evidence showing amio actually helps save lives in this setting? If there is none why is ACLS recommending it? Same goes for epinephrine.
    Dorian et al. and Kudenchuk showed that amio just led to more patients being admitted to the hospital to die or to be vegetables. Kudenchuk et al. in NEJM reported that the rate of survival with good neurologic recovery with amiodarone was similar to that without amiodarone. The benefit if any is so small that it is simply not practical from a cost-benefit comparison.
    There is now good evidence for esmolol in arrhythmogenic storm. ECMO looks promising in select patients.

    Also FYI- procainamide has been shown to be far better than amio at converting VT to sinus rhythm.

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