Amiodarone is a class III antiarrhythmic agent and is used for the treatment of various types of tachyarrhythmias. Because of the toxicity and serious side-effects of amiodarone, use it cautiously and do not exceed the cumulative total of 2.2 grams in 24 hours.
Indications for ACLS
Within ACLS, amiodarone is used for its antiarrhythmic properties and is effective for the treatment of supraventricular arrhythmias and ventricular arrhythmias.
The mechanism of action for amiodarone’s antiarrhythmic properties remains unclear, but it continues to be the primary antiarrhythmic medication for the treatment of ventricular fibrillation and ventricular tachycardia within the cardiac arrest algorithm.
For cardiac arrest, amiodarone is used after the third shock for ventricular fibrillation and ventricular tachycardia that is unresponsive to shock delivery, CPR, and vasopressors. For tachycardia with a pulse, amiodarone may be considered, and expert consultation should be obtained prior to its use.
Do not use amiodarone for individuals with polymorphic VT associated with a prolonged QT interval because this may worsen the patient’s condition.
Amiodarone is only used after defibrillation (or cardioversion) and epinephrine (first line medication) fail 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 that are not life-threatening, consider expert consultation 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
To prepare Amiodarone for an IV infusion, mix with D5W and give through an in-line filter. Alternatively, it is NOT necessary to dilute amiodarone for IV push administration and a filter is not necessary.
When infusions exceed 2 hours, amiodarone can absorb into the plastic used for standard IV bags. This will change the medication concentration. Therefore, when an infusion exceeds 2 hours use a glass or polyolefin bottle for the administration container.
Nino says
After reversion of atrial fibrillation to sinus rhythm, how long can be used antiarrhythmic drugs to prevent recurrent. Along with sotalol and amiodarone which antiarrhythmic drugs was proven in maintaining sinus rhythm?
Sorry for my bad english and Thank you for your website <3
ACLS says
I’m assuming that you meant ventricular fibrillation. If Antiarrhythmic medications are effective in reversing arrhythmias then those medications can be used to prevent reoccurrence of the arrhythmia. The three most common antiarrhythmics that are used are amiodarone, lidocaine, and sotalol.
Kind regards,
Jeff
KHALED Elnaggar says
During CPR, can we give amiodarone after 2nd shock?
ACLS says
According to the American Heart Association ACLS provider manual, amiodarone is to be given after the third shock during CPR.
If you are working with a team of providers and those providers deem it necessary to give the amiodarone in some other way to tailor the interventions to the specific scenario then that would be OK. American Heart Association allows for deviation from the guidelines depending on provider discretion.
Kind regards,
Jeff
steven says
If amio is just given and its also time for the next epinephrine to be given, would you give both around the same time?
After the second dose of amio, do you just continue giving epinephrine every 3-5min?
ACLS says
Amiodarone and epinephrine both can be given back to back during the same round of CPR.
After the first dose of epinephrine, it on its own timetable and is given every 3-5 minutes. You just have to make sure that it is given while chest compressions are being provided.
Kind regards,
Jeff
Jay Patel says
Hi, why don’t we give more amiodarone after the 2nd dose? Is OT becaus that’s about 10mins since the start of resuscitation so we consider prognosis or because of the side effects ,and if that which one is specific. Thanks
ACLS says
Additional doses may be given after the first dose of 300mg has been given. Additional doses after the first dose are 150 mg. Ensure that each dose has an adequate amount of time for distribution into the central circulation with chest compressions.
Kind regards,
Jeff
Kapos says
Hi
If a full dose of Amiodarone is given in a cardiac arrest (300×1 & 150×1)and rosc is achieved but the patient re arrests shortly after is this considered a new event and can you
re administer Amiodarone 300 & 150 again post 3rd and 5th shock if the pt stays in VF/VT,
Thanks
ACLS says
Any subsequent doses after the first dose of 300 mg are 150 mg. Subsequent doses may be given for refractory ventricular fibrillation or pulseless ventricular tachycardia.
The maximum cumulative dose for a 24 hour period is 2.2 grams.
Kind regards,
Jeff
Sanya says
Hi Jeff,
I have read a few articles about amiodarone but still do not get all ways it can be administrated.
In cardiac arrest we use it without dilutation, directly 300mg from 2 viels IV push, right?
But what about patient who has a puls but hemodinamic unstable, is it possible to dilute 6ml amiodarone (50mg/ml) with 14ml glucosae and give it as a 2 minutes bolus?
I do not understand how should we use it in VT in patient with puls, dilute 150mg with 100ml glucosae and give as a bolus over 10 minutes or like IV infusion (how many drops in a minute?)
Jeff with admin. says
Q: In cardiac arrest we use it without dilutation, directly 300mg from 2 viels IV push, right?
A: Amiodarone can be administered through in IV, I/O, or central line. Amiodarone may also be give orally in non-emergency situations.
Q: But what about patient who has a pulse but hemodinamic unstable, is it possible to dilute 6ml amiodarone (50mg/ml) with 14ml glucosae and give it as a 2 minutes bolus?
A: ideally we’re not dealing with cardiac arrest, IV bolus of amiodarone should be given over 10 minutes. A physician may deviate from administration time and give the medication quicker if they think that it is clinically necessary for the treatment of the patient.
Q: I do not understand how should we use it in VT in patient with pulse, dilute 150mg with 100ml glucosae and give as a bolus over 10 minutes or like IV infusion (how many drops in a minute?)
A: That is correct. Dilute 150 mg with 100 mL of D5W and give over 10 minutes. Drops per minute would depend upon the drip ratio for the infusion set being used.
The rate to infuse the medication would be 10 mL per minute. If using an infusion pump to do the 10 minute bolus, the rate would be set at 600 ml/hour for the 10 min.
Kind regards,
Jeff
Sam says
Is there a recommendation on the amount of time that can safely lapse before the amiodarone infusion is started? For example, if the drip is being compounded, does 5 minutes lapsing versus 10 minutes or 15 minutes become clinically significant? I am hoping for something other than a sooner versus later answer if possible.
Jeff with admin. says
It depends on the stability or instability of the patient. Amiodarone is quite effective for preventing tachyarrhythmias from degrading into VF. The sooner amiodarone is used for it antiarrhythmic properties, the more likely that it will be helpful in controlling a tachyarrhythmia.
Please let me know if you have any other questions.
Kind regards,
Jeff
ARLYN MAHIR says
When can we give the second dose of amiodarone 150mg? like after how many shocks?
Jeff with admin. says
The second dose of 150 mg of amiodarone maybe given anytime after the 4th shock during CPR. After the first dose, As long as the first dose of amiodarone has had sufficient time to fully enter the central circulation a second dose of amiodarone maybe given.
Kind regards,
Jeff
P says
Can the amiodarone bolus dose for tachycardia (not pulseless) be given as an undiluted iv push? I have heard you should never give amiodarone undiluted in an “alive patient”
Jeff with admin. says
In non-emergency situations, amiodarone should not be given undiluted IV push. A bolus dose should begin over 10 minutes.
Kind regards,
Jeff
Roberto Ruiz says
I pre-hospital resuscitations involving V-Fib, the likelihood of exhausting the total recommended for Amiodarone occurs(300mg and then 150mg); subsequently, after the administration of epinephrine and two minutes of CPR should we consider another drug like lidocaine or continue only with epinephrine.
Jeff with admin. says
The American Heart Association does not provide any guidance with regard to the use of multiple antiarrhythmics in a single setting during a code.
I have personally seen both amiodarone and lidocaine used during a code, but there are no specific recommendations.
I think there are no specific recommendations because there is no evidence to show that using multiple antiarrhythmics has any additional effectiveness.
The American heart Association recommends sticking with epinephrine every 3-5 minutes throughout the code. Once one of the antiarrhythmics has been attempted there is no recommendation for use of a Second antiarrhythmic.
Kind regards,
Jeff
Tsivia says
Can amiodarone be administered endotracheal?
Jeff with admin. says
Amiodarone can not to be administered by Endotracheal tube.
Amiodarone may only be administered by IV or oral route.
Kind regards,
Jeff
Azad says
how long CPR is continued between first dose of Amiodarone(300mg) and second dose
Jeff with admin. says
At least a full 2 minutes of CPR. It can be given any time during the any subsequent cycle of chest compressions.
Kind regards,
Jeff
Ashley says
Can amiodarone be given undiluted iv rapid push in case of cardiac arrest with vf without the filter?
Jeff with admin. says
Amiodarone can be given undiluted rapid IV push without a filter.
The filter is necessary because of the length of time that amiodarone sits in the bag. This provides ample time for precipitate to form. When amiodarone is given wrap at IV push this is not the case and no filter is necessary.
Amiodarone should be given undiluted and pushed as rapidly as possible during cardiac arrest.
Kind regards,
Jeff
Randy Cain says
Hi Jeff 🙂 .
“Amiodarone should only be diluted with D5W and given with an in-line filter.”
I’ve never given it during a code. Can you directly bolus what is in the crash cart in a vial? Does the above quote only apply to setting up an infusion?
Jeff with admin. says
That statement pertains to amiodarone when it is being added to diluent for an infusion.
In an emergency, the amiodarone can be drawn up directly out of the vial and administered IV push without delusion. It can be pushed rapidly and then followed with 20 mL of normal saline. It can also be pushed without a filter because the filter is for filtering precipitate that forms when amiodarone sits for longer links of time in a dilution.
Kind regards,
Jeff
learning says
360 mg IV over 6 hours (1mg/min) → Infusion #2 540 mg IV over 18 hours (0.5mg/min).
sorry admin.how to dilute this ?
Jeff with admin. says
Typically, the 360 mg will be diluted in 200ml of D5W.
Often times, these will be pre-mixed bags that are ready to go as is.
Kind regards,
Jeff