Amiodarone IV Push Administration
Amiodarone should NOT be given as a true "IV push" in the traditional sense—it must be administered as a controlled infusion over at least 10 minutes, even in cardiac arrest situations, to minimize life-threatening hypotension and hepatorenal toxicity. 1
Cardiac Arrest Protocol (VF/Pulseless VT)
For patients in ventricular fibrillation or pulseless ventricular tachycardia unresponsive to CPR and defibrillation:
- First dose: 300 mg IV/IO as a rapid bolus (administered over approximately 1-2 minutes during active resuscitation) 2
- Second dose: 150 mg IV/IO if VF/pulseless VT persists after the first dose 2
- This bolus dosing should only occur after multiple defibrillation attempts and epinephrine administration 2
Hemodynamically Stable Ventricular Arrhythmias
For stable ventricular tachycardia or breakthrough VF/VT episodes:
- Loading dose: 150 mg mixed in 100 mL D5W infused over 10 minutes 3, 1
- Do NOT exceed 30 mg/min infusion rate to prevent hepatocellular necrosis and acute renal failure 1
- This can be repeated if breakthrough arrhythmias occur 1
Standard 24-hour protocol following initial loading:
- 1 mg/min (360 mg) for first 6 hours 3, 1
- Then 0.5 mg/min (540 mg) for next 18 hours 3, 1
- Total first 24 hours: approximately 1000 mg 2, 1
Critical Administration Requirements
Equipment and access:
- Must use volumetric infusion pump—drop counter sets can underdose by up to 30% 1
- Administer through central venous catheter whenever possible 3, 1
- Use in-line filter during administration 3, 1
Concentration limits:
- For infusions >1 hour: do NOT exceed 2 mg/mL concentration unless using central line 1
- Concentrations >3 mg/mL cause high incidence of peripheral vein phlebitis 1
- Infusions >2 hours must use glass or polyolefin bottles with D5W 1
Contraindications and High-Risk Situations
Absolute contraindications:
Extreme caution required (relative contraindication):
- Heart rate <60 bpm without pacemaker—only use if immediately life-threatening and no alternatives exist 3
- Severe sinus node dysfunction 2
Bradycardia considerations:
- Drug-related bradycardia occurs in 4.9% of IV amiodarone patients 3
- If heart rate decreases by 10 bpm during infusion, reduce rate immediately 3
Monitoring Requirements
Continuous monitoring mandatory:
- ECG for heart rate, AV conduction abnormalities, QT prolongation 3
- Blood pressure—hypotension occurs in 16-26% of patients 3, 2, 4
- Watch for second- or third-degree heart block (absolute contraindication to continued therapy) 3
Special Considerations for Critically Ill Patients
Hypotension management:
- Occurs in approximately 26% of patients receiving IV amiodarone 2, 4
- Minimize risk by infusing 150 mg doses over full 10 minutes 1
- Hypotension may require vasopressor support 5
Renal impairment:
- Maintenance infusion up to 0.5 mg/min can be continued for 2-3 weeks regardless of renal function 1
- Rapid infusions at higher concentrations than recommended have caused acute renal failure and death 1
Drug interactions requiring immediate dose adjustments:
- Reduce digoxin by 50% immediately—amiodarone doubles digoxin levels 3, 6
- Reduce warfarin by 30-50% and check INR within 3-5 days 6
- Concomitant beta-blockers, calcium channel blockers increase bradycardia risk 3
Common Pitfalls to Avoid
- Never administer faster than 10 minutes for non-arrest situations—this causes severe hypotension and organ toxicity 1
- Never use concentrations >2 mg/mL peripherally for >1 hour—causes phlebitis 1
- Never use evacuated glass containers for mixing—causes precipitation 1
- Do not exceed 2100 mg in first 24 hours—associated with increased hypotension risk 1