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.
Rishi Patel says
1) what is the smallest/largest recommended daily dose of amiodarone?
2) what is the permitted daily intake of amiodarone?
Jeff with admin. says
Information provided is for emergency use. That is within the scope of ACLS.
1. The smallest dose is 150 mg IV push. The largest recommended dose is 300 mg IV push.
2. The permitted maximum dose for amiodarone is 2.2 g in a 24 hour
Kind regards,
Jeff
oranee says
after giving 300mg of amiodarone. and giving 150mg of amiodarone. we will be the next dose amiodarone ?
Jeff with admin. says
There are only 2 doses of amiodarone given during cardiac arrest. The 300mg dose and then the 150mg dose. Kind regards, Jeff
jonas ejercito says
after giving 300mg of amiodarone. when will be the next dose of 150mg amiodarone?
Jeff with admin. says
You can give the 2nd dose of amiodarone any time after the 4th shock as long as it is given while chest compressions are being performed. Also, you want to ensure that the 1st dose of amiodarone is fully circulated with high-quality CPR prior to the 2nd dose being given.
Kind regards,
Jeff
Kareemaldin says
Do we need 3 consecutive shocks to give amiodarone or we can give amiodarone after 3 interrupted shocks?
Jeff with admin. says
You would give the first dose of amiodarone after the 3rd shock. Between each shock there should be 5 cycles of CPR.
Kind regards,
Jeff
Dr.Hameed Chaudhari; Latur;India says
Do you suggest Oral Amidarone as a prophylactic Antiarrythmic Drug to a patient of Revived cardiac arrest ( V.Fib/pVT)
Jeff with admin. says
AHA no longer recommends the prophylactic use of amiodarone. Amiodarone can be used if VT or VF reoccur. In this case, an IV bolus of amiodarone would be the best choice. Oral amiodarone would not be a consideration within the critical care setting during an emergency.
Kind regards,
Jeff
Mg says
Can an Amiodarone infusion be ran into a chemport?
Jeff with admin. says
Do you mean a central line or a port-a-cath?
Jeff with admin. says
Do you mean a central line or a port-a-cath? Or do you mean a dedicated chemo port?
If you mean a central line or a port-a-cath then there would be no contraindication, but I would with the surgeon who put it in prior to using it if it was a dedicated chemo port.
Kind regards,
Jeff
Paula says
I just want to ask about amiodarone – to be given or not?
If there a VT with pulse in the ambulance on the way to the hospital, with poor ejection fraction and pulmonary oedema and BP at lower side at arrival to the A&E, would you consider still loading with amiodarone considering that might reocur? To be mentioned that in A&E dept he was in sinus rhythm ( spontaneous converted), but extensive ischemic changes in all ECG leads( that can also be associated with prolonged arythmia ).
The VT reocured 90 min later. It was pulsless VT and required shocked.
Jeff with admin. says
This depends on a number of things.
1. Was a 12 lead ekg done in the field prior to the ER
2. Was the 12 lead evaluated by an ER physician
I would want to get dispatch authorization through a physician to give any antiarrhythmic medication in a situation that falls outside of standing order protocol.
This is a complex case in which amiodarone might be indicated, but there are a lot of factors.
Personally, if the patient was stable during transport then I would hold off on the amiodarone until arrival to the ER so that the patient can be more thoroughly evaluated.
Kind regards,
Jeff
Alfred says
The acls algorithm says 1st shock -> cpr -> 2nd shock -> epi -> 3rd shock -> amio. What if my patient converts to a perfusing rhythm after the 3rd shock, will i still give amiodarone? Thanks.
Jeff with admin. says
You would not need to administer the amiodarone if ROSC occurs as stated above.
If the patient had refracture he V fib after this, amiodarone would be high on your priority list. You could basically start right where you left off and give your amiodarone after a shock.
Kind Regards,
Jeff
jane says
Thank you for this Q and A, i hope, they will include these possible questions in the lecture /protocol itself
Arlene Richards says
very informative blog!
Hatem says
Thanks for your clarification , I have a question
Amiodarone is given after 3rd shock.
That’s mean 3 consecutive shocks ,,, or 3rd shock rnen if seperated by un scohcable rhythm as ( shock , shock , unscockable, shock)Thanks
Jeff with admin. says
It would mean after the third shock even if the shocks were separated by other changes in the rhythm.
Also, there is a provider discretion and if a provider deems that it is necessary to give amiodarone earlier or not at all, they can use that expert discretion.
Kind regards,
Jeff
Stan says
1. Jeff, the algorithm states to give shocks if rhythm is shockable after one CPR cycle. Does this mean you need to wait through the CPR cycle? I’m pretty sure you just shock right away but I want to clarify.
2. The algorithm states for the 2nd CPR cycle, you find IV/IO access. If a nurse could find IV/IO access in the 1st CPR cycle, can we give epinephrine during the 2nd cycle? The algorithm states to give epinephrine on the 3rd cycle.
3. Similarly to #2, how strict is it that we give amiodarone on the 3rd CPR cycle? Do you only give amiodarone if shocking has failed x3 times? Could you mix amiodarone within one of those 3 shocks? For example, could we give it as early as in this situation. Pt unresponsive, pulseless with vfib. First start CPR, then you find rhythm is shockable, you deliver a shock and resume CPR but find pt is unresponsive to the first shock. At this time, can you give amiodarone AND/OR epinephrine during this CPR cycle? After CPR cycle you can shock again?
4. At my hospital, nurses tend to give amiodarone UNDILUTED. When I ask them why they don’t dilute in 10-20ml of D5W they tell me patient is presumed dead at the time and they don’t really care for the vein/tissue at the time. What do you normally say to these nurses?
5. Do you ever give an amio drip while pt is pulseless Vtach? It is not on the algorithm. Normally I see it AFTER ROSC.
6. If amiodarone 300mg and 150mg were given during the code, do you need to give an addition 150mg iv bolus prior to the drip?
Jeff with admin. says
1. The algorithm states to give shocks if rhythm is shockable after one CPR cycle. Does this mean you need to wait through the CPR cycle? I’m pretty sure you just shock right away but I want to clarify.
A: If the arrest was witnessed then you should provide a shock as soon as the defibrillator is available. If the arrest was unwitnessed, you should provide 5 cycles of CPR and then perform a rhythm check. If the rhythm check indicates shock then you would shock.
2. The algorithm states for the 2nd CPR cycle, you find IV/IO access. If a nurse could find IV/IO access in the 1st CPR cycle, can we give epinephrine during the 2nd cycle? The algorithm states to give epinephrine on the 3rd cycle.
A: If there is someone specifically focused on IV access and medication administration, you can diverge from the the algorithm and give the epinephrine earlier. The VF/pulseless VT algorithm places epinephrine after the second shock to ensure that medications are not made the focus.
3. Similarly to #2, how strict is it that we give amiodarone on the 3rd CPR cycle? Do you only give amiodarone if shocking has failed x3 times? Could you mix amiodarone within one of those 3 shocks? For example, could we give it as early as in this situation. Pt unresponsive, pulseless with vfib. First start CPR, then you find rhythm is shockable, you deliver a shock and resume CPR but find pt is unresponsive to the first shock. At this time, can you give amiodarone AND/OR epinephrine during this CPR cycle? After CPR cycle you can shock again?
A: You would want to ensure that the epinenephrine has been given time to circulate (5 cycles of CPR) prior to giving amiodarone. If the epinephrine has been circulated then it would be ok to give the amiodaonre as long as you are emphasizing high quality CPR and early defibrillation. Neither epinephrine nor amiodarone has been shown to improve survival to hospital discharge and therefore you should focus on those things which have been shown to improve outcomes. (i.e. high quality CPR and early defibrillation)
4. At my hospital, nurses tend to give amiodarone UNDILUTED. When I ask them why they don’t dilute in 10-20ml of D5W they tell me patient is presumed dead at the time and they don’t really care for the vein/tissue at the time. What do you normally say to these nurses?
A: At least follow the amiodarone with 20 ml NS. This helps to more effectively bolus the medication into the central circulation where it is needed. The key is to get the medication into the central circulation as quickly as possible. Ensure that HIGH QUALITY CPR is being performed. Meds are useless if CPR is ineffective.
5. Do you ever give an amio drip while pt is pulseless Vtach? It is not on the algorithm. Normally I see it AFTER ROSC.
A: I have never seen a amio drip the code. I quite frequently see amiodarone used after ROSC.
6. If amiodarone 300mg and 150mg were given during the code, do you need to give an addition 150mg iv bolus prior to the drip?
A: No. You need to follow the infusion guidelines. Infusion #1 360 mg IV over 6 hours (1mg/min) → Infusion #2 540 mg IV over 18 hours (0.5mg/min)
Kind regards,
Jeff
Sri says
Hi there, is there any antidote for overdose of amiodarone other than sympotamatic treatment??
Thanx.
Jeff with admin. says
I am not aware of any antidote for treatment of amiodarone overdose.
Activated charcoal can be given for a recent oral ingestion of excess amiodarone.
Symptomatic treatment would be the standard of care.
Kind regards,
Jeff
Shireen Squirrell says
Hi had this question for a mid term exam (I’m a student nurse): (a) If a patient in cardiac arrest had an Arterial Line in-situ and required IV Amiodarone, could you use the Arterial line for the administration?
I answered ‘no’ and was marked correct, but I’m not sure why this is the case? My teacher still hasn’t answered, so thought I would ask here.
Shireen Squirrell says
Oh, and thanks in advance. 🙂 This is a great site!
Jeff with admin. says
Arterial lines are generally not used to administer medication, since many injectable drugs may lead to serious tissue damage and even amputation if administered into an artery rather than a vein.
Kind regards,
Jeff
shireen says
Thanks very much, Jeff.
Josh says
What is the correct post resuscitation drip dosage for amiodarone?
Jeff with admin. says
In the event that arrhythmias persist, the post-arrest dosage for amiodarone is as follows:
Infusion #1: 360 mg IV over 6 hours (1mg/min) → Infusion #2: 540 mg IV over 18 hours (0.5mg/min)
Kind regards,
Jeff
Kelly Kallaher says
Can you document the source for this?
Jeff with admin. says
This maintenance dosing comes from the manufacturer here.
It also can be found in most IV medication reference books.
Kind regards,
Jeff