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.
Kathy Miller says
Two Questions: 1) Can this drug (amiodarone) be given above or below the drip chamber?
2) Is there an antidote or reversing agent?
Jeff with admin. says
Kind regards,
Jeff
Fred says
Is the prefilled suitable for mixing with 100mls D5W and given for unstable pulsed VT?
When I did my course a few years ago, they said that only glass amps mixed up was to be used, now we just mix half the pre-filled into the bag and given that over 20mins?
Jeff with admin. says
If the amiodarone is pre-mixed, then you would not need to add any more diluent. You can just follow the instructions for administration of the 2 amiodarone infusions as directed for unstable VT with a pulse.
Kind regards,
Jeff
Victoria says
What is the amount of time you need to wait between the first 300mg and second 150mg dose of amiodarone?
Jeff with admin. says
At least 1 cycle of CPR and Shock. After this, the 2nd dose of amiodarone may be given.
Kind regards,
Jeff
miz says
at what point in the cycle do you actually give the amio during the cardiac arrest protocol? (assuming shockable rhythm) after the 1st epi? or after the 1st, 2nd, or 3rd shock?
Jeff with admin. says
After the 3rd shock, just as chest compressions commence.
Kind regards,
Jeff
Wipharak Bunark says
Why do ACLS guideline suggest the maximum cumulative dose of amiodarone at 2.2 g?
Jeff with admin. says
This is to help prevent liver toxicity which is one of the side effects of receiving persistent amounts of excess amiodarone. Kind regards, Jeff
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!
Jeff with admin. 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
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
Jeff with admin. 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
Mickey says
Why is it only diluted in D5W? Thanks
Jeff with admin. 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
gigi chacko says
Does Amidarone need to be diluted in 20-30 ml of NS or D5 W during cardiac arrest?
Jeff with admin. says
It should be diluted in at least 10 ml of D5W for IV push use during cardiac arrest.
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.
Jeff with admin. says
This was my mistake. I should have said “It should be
dilutedreconstituted 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
steve says
Does amiodarone always need a loading dose? if not could you please cite references
Jeff with admin. 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
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??
nick says
in ROSC after asystole why not use amiodarone if there is a possibility that vf/vt can occur?
Jeff with admin. 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
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)
Jeff with admin. 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
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
Jeff with admin. 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
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.
Jeff with admin. 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