Are there any indications for giving an amiodarone (amio) bolus without a drip?

Amiodarone Bolus Without Drip: Clinical Indications

Yes, there are specific indications for giving an amiodarone bolus without a maintenance drip, primarily in the cardiac arrest setting for shock-refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT).

Primary Indication: Cardiac Arrest with VF/pVT

The American Heart Association guidelines explicitly support bolus-only dosing of amiodarone during cardiac arrest resuscitation for shock-refractory VF/pVT. 1

Dosing Protocol for Cardiac Arrest

• First bolus: 300 mg IV/IO administered rapidly 1
• Second bolus (if needed): 150 mg IV/IO 1
• No maintenance infusion is specified or required in the cardiac arrest algorithms 1

Key Clinical Context

• Amiodarone boluses are given after CPR, defibrillation attempts, and vasopressor (epinephrine) administration have failed to terminate VF/pVT 1
• The goal is immediate rhythm conversion during active resuscitation, not long-term rhythm maintenance 1
• These boluses improve short-term outcomes like return of spontaneous circulation (ROSC) and survival to hospital admission, though no antiarrhythmic has proven long-term survival benefit 1

When Maintenance Infusion IS Required

Life-Threatening Arrhythmias with Perfusing Rhythm

• For hemodynamically stable ventricular tachycardia or recurrent arrhythmias requiring ongoing suppression, the standard protocol includes both loading and maintenance infusion 1
• Loading: 150 mg IV bolus over 10 minutes, then 1 mg/min for 6 hours, then 0.5 mg/min for 18 hours 1

Post-ROSC Considerations

• After successful resuscitation, prophylactic antiarrhythmic infusion may be considered to prevent recurrent arrest, particularly during transport 1
• However, this represents a different clinical scenario than the initial cardiac arrest bolus dosing 1

Critical Safety Considerations

Hypotension Risk

• IV amiodarone causes hypotension in approximately 16% of patients due to vasoactive solvents and vasodilation 2
• Bolus administration during cardiac arrest carries lower hypotension risk because patients are already pulseless and receiving vasopressors 1
• In perfusing patients, slower infusion rates (over 10 minutes minimum for 150 mg dose) are essential to minimize hypotension 2

Contraindications for Bolus-Only Approach

• Do NOT use amiodarone bolus for pulseless electrical activity (PEA) or asystole - it is only indicated for VF/pVT 3
• Amiodarone is contraindicated in patients with bradycardia or heart block without a pacemaker 2

Practical Algorithm

During Active Cardiac Arrest (Pulseless Patient)

1. Confirm rhythm is VF or pulseless VT 3
2. Ensure CPR quality, defibrillation attempts, and epinephrine have been given 3
3. Administer 300 mg amiodarone IV/IO bolus (can be given undiluted for speed) 4
4. Continue CPR and defibrillation attempts 1
5. If VF/pVT persists, give second 150 mg bolus 1
6. No maintenance drip needed during pulseless arrest 1

After ROSC (Return of Pulse)

1. Reassess need for ongoing antiarrhythmic therapy 1
2. Consider maintenance infusion if recurrent arrhythmias are anticipated 1
3. Transition to oral dosing when clinically appropriate 1

Common Pitfalls to Avoid

• Never combine amiodarone with lidocaine - use one or the other, never both, due to increased toxicity risk without proven benefit 5
• Do not delay CPR or defibrillation to prepare amiodarone infusion - bolus dosing allows rapid administration 4
• Undiluted amiodarone can be safely used in cardiac arrest settings when time is critical, without causing unmanageable hemodynamic effects 4
• Remember that amiodarone boluses during cardiac arrest represent a Class IIb recommendation (may be considered), not Class I (should be done) 1