What is the recommended infusion protocol for Amiodarone (antiarrhythmic medication)?

Amiodarone Infusion Protocol

For life-threatening ventricular arrhythmias, administer an initial loading dose of 150 mg IV over 10 minutes, followed by 1 mg/min for 6 hours, then 0.5 mg/min for the remaining 18 hours, with a maximum total dose of 2.2 g over 24 hours. 1, 2

Initial Loading Protocol

The FDA-approved dosing regimen delivers approximately 1000 mg over the first 24 hours using this three-phase approach: 2

• Rapid loading bolus: 150 mg IV over 10 minutes (can be repeated once if VF/pulseless VT persists) 1, 2
• Slow loading infusion: 1 mg/min for 6 hours (360 mg total) 1, 2
• Maintenance infusion: 0.5 mg/min for the remaining 18 hours (540 mg total) 1, 2

For cardiac arrest with VF/pulseless VT unresponsive to defibrillation and epinephrine, use 300 mg IV/IO bolus over 10 minutes, with a second 150 mg bolus if the rhythm persists. 3

Breakthrough Arrhythmia Management

If breakthrough episodes of hemodynamically unstable VT or VF occur during maintenance infusion: 2

• Administer supplemental 150 mg boluses mixed in 100 mL D5W over 10 minutes 2
• The maintenance infusion rate may be increased to achieve effective arrhythmia suppression 2
• Do not exceed 2.2 g total dose in 24 hours 1, 2

Administration Requirements

Critical administration details to prevent complications: 2

• Use a volumetric infusion pump (drop counter sets can underdose by up to 30%) 2
• Administer through a central venous catheter whenever possible 2
• Use an in-line filter during administration 2
• For concentrations >2 mg/mL, a central line is mandatory 2
• For infusions >1 hour, do not exceed 2 mg/mL concentration unless using a central line (higher concentrations cause severe peripheral vein phlebitis) 1, 2
• Administer in glass or polyolefin bottles containing D5W for infusions exceeding 2 hours 2
• Never use evacuated glass containers (causes precipitation) 2

Monitoring During Infusion

Watch closely for these dose-related adverse effects: 1, 4

• Hypotension (occurs in 16% of IV patients; most common adverse effect) 1, 4
• Bradycardia (occurs in 4.9% of IV patients) 4
• AV block and heart block 1, 4
• QT prolongation (common but rarely causes torsades de pointes) 4
• Phlebitis at infusion site 1

The initial infusion rate should never exceed 30 mg/min to minimize hypotension risk. 2

Extended Maintenance Therapy

After the first 24 hours: 2

• Continue 0.5 mg/min (720 mg per 24 hours) using 1-6 mg/mL concentration 2
• Maintenance infusion can continue for 2-3 weeks regardless of age, renal function, or left ventricular function 2
• Limited experience exists beyond 3 weeks of continuous IV therapy 2

Common Pitfalls to Avoid

Do not use faster infusion rates or higher concentrations than recommended - this has resulted in hepatocellular necrosis, acute renal failure, and death. 2 Mean daily doses above 2100 mg are associated with increased hypotension risk. 2

The drug shows considerable interindividual variation in response, requiring close monitoring with dose adjustment. 2 PVC tubing leaches plasticizers (DEHP) when using higher concentrations and lower flow rates, though all clinical experience has been with PVC tubing at the recommended concentrations. 2