What is the recommended fluid for dilution of amiodarone (antiarrhythmic medication) in an adult patient with potential heart failure and impaired renal or hepatic function?

Recommended Fluid for Amiodarone Dilution

Amiodarone must be diluted in 5% dextrose in water (D5W) for intravenous administration; normal saline should never be used as it causes precipitation. 1

Dilution Requirements by Administration Route

Intravenous Bolus Dosing

• Dilute 150 mg amiodarone in 100 mL of D5W for supplemental bolus doses administered over 10 minutes to minimize hypotension risk 1
• The 300 mg loading dose should be diluted in 20 mL of 5% dextrose for bolus administration 2

Continuous Infusion Dosing

• Mix 900 mg amiodarone in 500 mL D5W for the standard 24-hour maintenance infusion 1
• Concentrations should range from 1-6 mg/mL, though concentrations above 2 mg/mL require central venous access 1
• For peripheral venous administration, do not exceed 2 mg/mL concentration as higher concentrations cause severe phlebitis 1

Critical Container and Tubing Requirements

Container Selection

• Use only glass or polyolefin bottles for infusions exceeding 2 hours 1
• Never use evacuated glass containers for admixing, as buffer incompatibility causes precipitation 1
• PVC containers are acceptable for short-term use, though amiodarone adsorbs to PVC and leaches plasticizers including DEHP 1

Administration Equipment

• Always use a volumetric infusion pump—drop counter sets cause up to 30% underdosing due to altered surface properties 1
• Use an in-line filter during administration 1
• Administer through a dedicated central venous catheter whenever possible 1

Incompatibilities and Stability

Compatible Additives in D5W

• Potassium chloride, lidocaine, procainamide, verapamil, and furosemide remain stable when mixed with amiodarone in D5W for 24 hours at room temperature 3

Incompatible Combinations

• Never mix amiodarone with quinidine gluconate in PVC containers—this causes visual incompatibility and concentration loss exceeding 10% 3
• Normal saline causes precipitation and is absolutely contraindicated 1

Special Considerations for High-Risk Patients

Patients with Heart Failure or Hypotension

• Use slower infusion rates in patients with recent heart failure decompensation or baseline hypotension 4
• The hypotensive effect results from vasoactive solvents causing vasodilation rather than negative inotropy, occurring in approximately 16% of patients 4
• If hypotension develops, immediately slow or temporarily discontinue the infusion 4

Patients with Hepatic or Renal Impairment

• Standard D5W dilution remains appropriate regardless of hepatic or renal function 2
• Intravenous amiodarone loading at concentrations or rates exceeding recommendations has resulted in hepatocellular necrosis, acute renal failure, and death 1
• Monitor liver enzymes every 6 months during maintenance therapy, as 13% develop clinically significant elevations 4

Common Pitfalls to Avoid

• Never use normal saline—this is the most critical error causing immediate precipitation 1
• Do not exceed initial infusion rate of 30 mg/min, as rates above this threshold significantly increase hypotension risk 1
• Avoid concentrations above 2 mg/mL for peripheral administration—this causes severe phlebitis requiring central access 1
• Do not use drop counter infusion sets, which cause significant underdosing 1