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.
Josh says
“persistent VF/VT w/o a pulse”
What is the minimum/maximum amount of time between the first Amio bolus of 300 mg and the second Amio bolus of 150 mg?
Jeff with admin. says
Minimum is 3-5 minutes of high quality cpr after the first dose. Most important thing is that the first dose be adequately circulated before a second dose is given.
There is no maximum.
Kind regards,
Jeff
Richard says
Hello Jeff,
Another question about amiodarone. For example, if you are on non shockable rythm like PEA and you if you have already given 4 shocks and with the next rhythm check you realize that the rhythm is now shockable rhythm, what do you exactly do with the amiodorone? do you still give the 300mg or you just omit once the algorithm says to give after the 3rd shock?
Thank you very much
Jeff with admin. says
You can give the amiodarone in this situation.
Kind regards,
Jeff
Lahaynes says
EXcellent info and especially retaining by the way it’s presented! Thank You
Ali says
If a patient has been converted to sinus rhythm after pulseless VT, then whtas the recommendation for amiodarone maintenance infusion?. Is it mandatory or not…..? And plz answer regarding guidelines?
Jeff with admin. says
AHA Guidelines state that a maintenance infusion of amiodarone during the post-cardiac arrest phase of ACLS is recommended for use only if there are continued arrhythmias during the post-arrest phase.
Kind regards,
Jeff
Caroline Thibodeau says
Je me questionne: peut-on diluer l’amiodarone avec du NS ou non ?
En code, nous installons un soluté de NS flush et injectons la médication par la tubulure de ce dernier; est-ce ok ?
Parce que je lisais que la perfusion d’amio se fait dans du D5 (pourquoi pas du NS ?);
et on dit de faire suivre l’injection rapide d’un 20 ml de NS (pourquoi pas du D5% ?), alors qu’on dit de diluer le bolus d’amio dans du D5%….
Merci !
Jeff with admin. says
Amiodarone should only be diluted with D5W. There is one exception to this. The brand of amiodarone called Nexterone may be diluted in D5W or NS. The reason why other brands cannot be diluted with NS is that there is a high likelihood that precipitation can occur and there could be solid particles form within the solution.
Any type of Amiodarone may be followed by a NS push. This is OK since the period of time that the amiodarone will be in contact with the NS is very short and there will be no time for precipitation to occur.
Kind regards,
Jeff
Jannaina says
if I identified the cause of cardiac arrest in VT such as hypokalemia, should I still prescribe the maintenance amiodarone as infusion #1 and #2? Will amiodarone be discontinued once you have finished the infusion #2?
Jeff with admin. says
A post-arrest maintenance infusion of amiodarone will be given only if there are continued tachyarrhythmias in the post-arrest period. If the hypokalemia has been corrected and the tachyarrhythmias continue that an amiodarone infusion would be indicated. Kind regards, Jeff
Eric Ha says
HI
The concentration of amiodarone we have in our hospital is 50mg/1mL and on the vial, it said “Must be diluted . For IV use only.” So can I still push this and flush with 20 mL of NS; if not, then how much volume of D5W I should dilute with and how much is for the flush to follow?
Thanks
Jeff with admin. says
For emergency cardiac arrest situations, the dose of 300 mg can be given undiluted and then followed with 20 ml of NS. The dose you are working with is 50mg/ml. This would mean you would need 6 ml. It would be ok to dilute this in another 4 ml of D5W or compatible solution which would give you 300 mg/10 ml.
Kind regards,
Jeff
art says
why amiodarone is not given in unstable vt,a patient known to have poor lv,with pulmonary edema and pulse vt, in this scenario why amiodarone is not preferred over cardioversion?
Jeff with admin. says
For the treatment of unstable ventricular tachycardia, cardioversion is rapid and effective with minimal side effects. This is the reason why you would attempt cardioversion for unstable ventricular tachycardia with a pulse before you would give amiodarone as an antiarrythmic therapy.
Kind regards,
Jeff
MG says
I think most of us have amiodarone as a solution rather then powdered form..
Can you summarize the dosage/rapid or slow push/dilution/indication in ACLS of amiodarone please…. Thanks…
Jeff with admin. says
For the treatment of pulseless VT and VF, the first dose of amiodarone is given 300 mg IV push. You can give this as a rapid IV push. Push it as fast as you can push the plunger on the syringe without infiltrating the IV. For cardiac arrest, the amiodarone can be given undiluted.
Kind regards,
Jeff
MG MG says
In VT/VF pulseless arrest, 1st dose (300mg) and 2nd dose (150mg) of Amiodarone, do they need to be pushed rapidly as in adenosine with arm raised? Does it need NS flush?
Jeff with admin. says
It does not have to be pushed in the same manner as adenosine. The reason why adenosine is pushed as described above is because of the very short half-life of medication. The goal is to get the bolus of adenosine to the heart as rapidly as possible in a concentrated dose.
Amiodarone’s half-life is very long (58 days), therefore, you would not need to worry about the medication being pushed in the same way as adenosine. For cardiac arrest, Amiodarone should be pushed quickly and then followed with 20 ml of NS. This can be 15, 30, or 60 sec. The sooner that it is in the system, the sooner it will be able to have its antiarrhythmic effects on the body.
Kind regards,
Jeff
Nikki says
Hi, when giving amiodarone as a 300 mg IV/IO push, is this undiluted ? and if so what is the flush if it precipitates with Normal saline.
Thanks
Jeff with admin. says
Typically amiodarone comes as a powder and must be diluted in 10 ml of D5W in the bottle. In emergency situations, after diluted with the 10 ml of D5W it can be administered rapid IV push.
In non-emergency situations, this 10 ML of amiodarone would be diluted further in at least 150 ML of D5W.
Precipitation typically is a process that occurs when one solution is mixed with another. The precipitate forms because the solid is insoluble in water.
When a rapid bolus is performed, the saline pushes the amiodarone into the system, there would not be enough of the amiodarone present against the saline to cause precipitation.
Kind regards,
Jeff
Catherine says
Hi Jeff, amiodarone comes as a liquid where I work, so give 300mg IV push undiluted and followed by 20cc D5W or 20cc NS?
Jeff with admin. says
Normal Saline is fine. The reason why it is OK is because the bolus of amiodarone will be pushed in by the normal saline, and there will be an insignificant amount of mixing. Definitely not enough time or amount to cause any type of precipitation.
Kind regards,
Jeff
Park says
So why amiodarone should mixed with d5w?, why dosent have to mixed with saline??
Jeff with admin. says
It is my understanding that amiodarone tends to precipitate and create sediments when NS is used rather than D5W.
Kind regards,
Jeff
Elaine McKinney says
I think I got lost on amiodarone. can you give for SVT?
Jeff with admin. says
Amiodarone can be used for the treatment of SVT, but it would typically not be used as a primary medication. There are other interventions that would be more effective than amiodarone. For instance, vagal maneuvers and adenosine can be used for the treatment of SVT and they both have a very high success rate for conversion from SVT.
Where amiodarone may come into play is for SVT that is does not seem to respond to vagal maneuvers or adenosine. It may also be used in the case where they can maneuver’s or adenosine only temporarily reduce the heart rate and convert the rhythm.
Kind regards,
Jeff
Jeff Budyer Loremia says
As stated in Adult Cardiac Arrest Algorithm, how epinephrine will be administered along with amiodarone during the second cycle of shockable event?
Jeff with admin. says
The 2nd epinephrine dose can be administered before or after the amiodarone. Give one of the medications then rapidly flush with 20 ML’s of NS then give the second medication and rapidly flush with 20 ML’s of NS.
Kind regards,
Jeff
Jo Botello Humann says
In a patient in A-Fib with RVR receiving an ongoing infusion, what is the recommended IV gauge and site recommended? Also, does the FDA approve this drug as a first line treatment for this indication?
Jeff with admin. says
There is not a recommended size catheter. My recommendation would be the best gauge is the one you can get in. Typically 18 g or 20 gauge would be ideal, but not by any means necessary. Amiodarone is a potent antiarrhythmic agent that is used to treat ventricular arrhythmias and atrial fibrillation.
Kind regards,
Jeff