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.
Lillian says
Is there any reason that if an IV or IO is established early on, that the first dose of amiodorane can’t be given after the second shock? With epinephrene given in between the first two?
Thank you
ACLS says
The American Heart Association ACLS guidelines place amiodarone after the third shock in the left branch of the cardiac arrest algorithm. There are two main reasons for this. First, the early administration of amiodarone may delay other more important interventions, and second, there are no studies that have shown amiodarone increases survival to hospital discharge. Therefore, the American Heart Association deemed Amiodarone as a medication that should be of less importance with regard to early interventions.
Kind regards,
Jeff
Mike Chudyk says
Is there any information about filtering Amiodarone drip when infusing via a Central or Peripheral IV line?
Also, what would be the correct filter size.
With regards to IV tubing for Amiodarone infusions, what options would one consider to safely infuse the Amiodarone.
Thank you.
ACLS says
For administration purposes during cardiac emergencies, amiodarone is administered rapidly and undiluted, therefore filtration is not necessary.
Filtration is used when amiodarone is diluted to prevent precipitates from entering into the vascular system. When amiodarone sets in solution for any length of time precipitates can form. In this case, use of a 0.2 or 0.22 micron filter is recommended for intermittent and continuous infusions.
Kind regards,
Jeff
Corey says
Hello Jeff, wondering if you could help me out with the reason why Amiodarone is incompatible with normal saline, in terms of what effects it has on the body and why we give it with D5W?
Regards, Corey
ACLS says
Amiodarone is incompatible with normal saline. When amiodarone is diluted with normal saline this can cause precipitates of the amiodarone resulting in formation of small crystals that are not safe when entering the vascular system.
Kind regards,
Jeff
niniko says
Case when VT caused by ACS. If it terminates after SHOCK delivery, should we start amiodarone infusion to prevent further VT event? Or after recanalization of coronary artery there is no indication of ROUTINE amiodarone infusion and beta-blockers are sufficient for further prevention of VT.
Could you answer, plz…
ACLS says
There is no routine prophylactic use of amiodarone. If ventricular tachycardia or ventricular fibrillation reoccur or if you move through the second shock and the arrhythmia continues then you would initiate intravenous amiodarone.
Kind regards,
Jeff
niniko says
Words “amiodarone after the 3rd shock” mean ongoing first episode of VT/VF which can not terminate in two previous shocks, or mean that 2 episodes of VT/VF successfully terminated before with shock and there is a recurrent, 3rd episode of VT when amiodarone can be used.
Return of spontaneous circulation after amiodarone bolus, often must be followed with maintenance infusion?
Thank you, very much.
ACLS says
For both of those scenarios you would begin amiodarone. Amiodarone is used in the case of recurrent ventricular tachycardia or ventricular fibrillation and also in the case of non-responsive ventricular tachycardia or ventricular fibrillation. Kind regards, Jeff
Zach says
Have you found any information stating why Amio is such a late option in the ACLS algorithm? Based on the medication’s Mechanism of Action it seems like pushing it prior to the first shock would actually benefit those in V. FIb.
ACLS says
The American Heart Association has placed amiodarone and all other medications as a low priority since there is no evidence that any medication improves survival to hospital discharge. All medications now receive a lower priority in relation to CPR and defibrillation.
Kind regards,
Jeff
Beqa says
Patient with NSTEMI, on monitor sinus rthytm changed to VT and within 10 second patient lose consciusness. Doctor restored thythm with immediate defibrillation, patient now is consciousness. But, 5 minutes latter patient say that he feel the same palpitation like 5 minutes ago; monitor show the same VT. Now, doctor didn’t wait until patient become unconciousness and gave him shoke. Patient shout back, due to pain following shoke/defibrillation. Should doctor wait 10 second or more until patient become unconsciousness and then give him a shoke; or what is the best choice?
When monitor showed repeated VT, must doctor use/try amiodarone 150 or 300 mg bolus, before patient become unconsciusness? and when he become unconsciusness (within seconds), then give him a shock/defibrillation?
I hope you understent my question. It’s difficult due to my not good inglish <3
ACLS says
In the situation you have described, if there is no alternative to sedate the patient then I would shock them even if they were awake and alert. They can be mad at you for saving their life.
Kind regards,
Jeff
Mike says
Why is the first dose higher than the second if the first dosage didn’t convert the rhythm?
ACLS says
Amiodarone has a very long half life (58 days). So the objective is to increase the plasma level of amiodarone without making the patient amiodarone toxic. Typically, the initial dose will provide sufficient plasma levels, in the event that it does not, a second smaller dose is given. This prevents overdosing and keep you well under the 24 hour per day limit of 2.2 g.
Kind regards,
Jeff
Jodi says
Patient in VTach with a pulse what dose of amiodarone is given and over how long?
ACLS says
I am assuming that you mean stable ventricular tachycardia with a pulse. This would be covered with the tachycardia algorithm, and the dose would be 150 mg and it would be administered over 10 minutes. Repeat as needed if VT recurs. Follow this with a maintenance infusion of 1 mg/min for the first 6 hours and then 0.5 mg/min for 18 hours.
Kind regards, Jeff
Esther Edoh says
Thank you very much for the right dosing for Amiodarone during A CLS code and subsequence iV infusing pump speed dosing.
ACLS says
Your Welcome!
nini says
For restore sinus rthythm in atrial fibrillation we use the same dose of amiodarone as for STABLE, MONOMORPHIC, REGULAR ventricular tachycardia WITH a PULSE? I mean, we use first dose 150mg, follow by maintenance infusion of 1mg/min for first 6 hours, or there are some differences? Must we use low maintenance doses for AF in comparison to stable VT?
<3
ACLS says
The treatment for stable atrial fibrillation will vary from the treatment for acute tachyarrhythmias. Amiodarone may not be the best option when treating STABLE atrial fibrillation.
If amiodarone is chosen for this situation, the medication dosages would be the same.
For the treatment of all ACUTE tachyarrhythmias in adults, amiodarone can be given IV 150 mg over 10 minutes, followed by a 1 mg/min infusion for 6 hours, followed by infusion at 0.5 mg/min.
Kind regards,
Jeff
Niniko says
Upon return of spontaneous circulation, follow with an infusion of 1mg/minute for 6 hours (total 360mg), then 0.5mg/minute for 18 hours (total 540mg).
If we dilute it in 50ml infusion pump, speed for which amiodarone must be given is 8.3ml/h for 1mg/minute and 2.7ml/h for 0,5mg/minute. Is it true or not? I calculated it wrong or not?
I hope you understand what i mean <3
Niniko says
Or can we dilute 900mg (6 ampule) in 50ml infusion pump and given it for 1mg/min in speed 3.3ml/h for 6h and than for 0.5mg/min in speed 1.6ml/h for 18h. It is rigt speed or not?
sorry, for my english.
ACLS says
The second method you used would be a better way of explaining how to mix and infuse the medication. The second calculation is correct.
Here is a calculator that allows you to perform calculations for IV infusions.
Infusion Calculator
Kind regards, Jeff
Ana says
Can you comment about premature ventricular contractions, when should we treat it. What if PVC (Lown grading system – Grade 2) is asymtomatic in person with EF-45 and past MI, should we prescribe cordarone with beta blocker? sorry for my english.
ACLS says
The interventions for this would be beyond the scope of ACLS. That said, this would most likely need to be evaluated by a cardiologist. With the history of decreased EF and MI, it would be reasonable to suspect that some type of anti-arrhythmic would prescribed.
Kind regards,
Jeff
agsas80 says
i had a question, if the patient was in cardiac arrest , shockable rythm and the algorithm was used and after giving the 2nd dose of amiodarone ( ie after 5th cycle) i gave 150 mg amio , then 2 minute cycle passed and 1 mg epinephrine given , then 2 min cycle again passed , what is the next dose of amiodarone ? do we repeat it or no ??
ACLS says
Another dose of 150 mg of amiodarone maybe given.
You would give: 300mg – 150mg – 150mg
I have never seen more than three doses given during a code for cardiac arrest.
Kind regards,
Jeff
cled says
To prepare Amiodarone for an IV infusion, mix with D5W .i would to ask how many ml of D5W.thank you
ACLS says
Dilute 150 mg with 100 mL of D5W and give over 10 minutes.
Kind regards, Jeff
Atheana says
Im confused about the amount of times we can give amiodarone. 300mg x1 then 150mg x1 then subsequent doses of 150mg prn until 2.2 grams is reached in 24 hours. Also do we need to dilute and how much dilution does it need during a code. Lastly when indicated as rapid iv push . Does that mean to push as fast as you can. Please give an exact and detailed answer.
Thanks
ACLS says
“300mg x1 then 150mg x1 then subsequent doses of 150mg prn until 2.2 grams is reached in 24 hours.”
Your above statement is correct. Subsequent doses of 150 mg can be given as needed for the treatment of arrhythmias. Dilute 150 mg in 10 mL of D5W during a code and give rapid IV push (push as fast as you can). Also, follow the amiodarone with a 20 mL NS flush.
Kind regards,
Jeff
Diego says
Just read that amio IVP should be diluted in D5 is this true?
ACLS says
Yes that is true. Amiodarone is diluted with D5W
Kind regards, Jeff
reyhoon says
excuse me i have a question we just dilute the 3th dose of amiodarone with 10 cc d5w ?i mean the first and second dose dont need dilution?
ACLS says
During cardiac arrest any amiodarone that is given IV push does not need to be further diluted from what was in the vile That it was drawn out of.
Kind regards,
Jeff