ANNE ARUNDEL MEDICAL CENTER

CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY

Guidelines for Use of Intravenous Amiodarone (Cordarone®1)

Major Indications • Life threatening ventricular arrhythmias. According to the ACLS 2000 Guidelines, amiodarone is

now recommended ahead of other traditional antiarrhythmics in many cases. • Refractory sustained paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia

Mechanism of Action Amiodarone increases the cardiac refractory period without influencing the resting membrane potential. Amiodarone relaxes vascular smooth muscle, reduces peripheral vascular resistance, and slightly increases cardiac index. Pharmacokinetics

Onset of Effect Peak Effect* Duration of Effect IV 15 mins 15 mins after load 1 month after discontinuation PO 3-6 weeks Several months 1 month after discontinuation

Dosage and Administration Note: A final filter is required on amiodarone infusions. Initial 24 hours: Loading Dose: Infuse 150 mg IV over 10 mins followed by 360 mg IV over 6 hours (1 mg/min) Maintenance Infusion: Drip is initiated at 0.5 mg/min IV after the loading period delivering 540 mg over

the next 18 hours. If breakthrough arrhythmias occur, supplemental infusions of 150 mg given IV over 10 mins may be used to control the event.

Subsequent hours: Maintenance Infusion: Intravenous drip is maintained at 0.5 mg/min. It may be necessary to continue

the infusion for 48-96 hours. If breakthrough arrhythmias occur, supplemental infusions of 150 mg given over 10 mins may be used to control the event.

Monitoring • Continuous EKG • Blood Pressure (Continuously during initial loading period) • Liver function tests

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Contraindications • Hypokalemia, Hypomagnesemia (need to be corrected prior to Amiodarone use) • Cardiogenic Shock • Sinus Bradycardia • 2nd or 3rd degree AV Block

Adverse Reactions 1. Cardiac: Hypotension, bradycardia, AV block, arrhythmias 2. Resp: Interstitial pneumonitis, ARDS 3. CNS: Malaise, muscle fatigue, ataxia, dizziness, and paresthesias. 4. Hepatic: Elevated liver function tests 5. GI: Nausea, vomiting, constipation Overdose/Toxicity Excessive doses may produce sinus bradycardia +/- block (may be resistant to atropine & require pacing with isoproterenol or temporary pacer), hypotension, and Q-T prolongation. Drug Interactions 1. Amiodarone is incompatible with the following medications: Aminophylline, Cefazolin, Heparin, and

Sodium Bicarbonate. 2. Concommitant use of Amiodarone with Digoxin may lead to elevated serum digoxin levels and

digoxin toxicity. Digoxin dosage adjustments should be considered and frequent monitoring of digoxin levels is recommended.

3. Concomitant use of procainamide or quinidine with amiodarone may lead to elevated procainamide and quinidine levels.

4. Prolonged prothrombin times have been reported in patients receiving amiodarone and warfarin. Close monitoring and dosage adjustments are recommended.

5. Amiodarone should be used cautiously in patients also receiving calcium channel blockers or beta- blockers since potentiation of bradycardia, sinus arrest, or AV Block may occur.

6. Two to three fold increases in phenytoin levels have been reported in patients receiving amiodarone in combination with phenytoin.

Comments 1. Conversion to oral Amiodarone: IV Amiodarone Duration Daily Dose of PO Amiodarone <1 week 800-1600 mg 1-3 weeks 600-800 mg >3 weeks 400 mg

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ANNE ARUNDEL MEDICAL CENTER

CRITICAL CARE MEDICATION MANUAL DEPARTMENT OF NURSING AND PHARMACY

IV Additive Services

Medication Name Storage Requirements Preparation Resulting Concentration

Stability

Amiodarone Room Temperature Initial Bolus (150 mg over 10 mins): Add 150 mg amiodarone (3 ml of Amiodarone 50 mg/ml) to 100 ml D5W Baxter viaflex bag. Yields: 150 mg/ 100 ml Supplemental Bolus ( 360 mg over 6 hours): Withdraw 81 ml from Excel brand 250 ml D5W plastic bag to get 192 ml. Add 200 mg amiodarone (8 ml of amiodarone 50 mg/ml) to 192 ml D5W for final volume 200 ml. Yields: 400 mg/200 ml. Maintenance Infusion: Add 15 ml of D5W to Excel brand 250 ml D5W plastic bag, then add 600 mg Amiodarone (12 ml of amiodarone 50 mg/ml) for final volume 300 ml.. Yields: 600 mg/ 300 ml

1.5mg/ml

2 mg/ml

2 mg/ml

2 hours at room temperature 24 hours at room temperature 24 hours at room temperature

Trade Name: Cordarone® Notes: 1. Initial bolus in infused over 10 mins (600 ml/hr) 2. Supplemental infusion is infused over 6 hours (30 ml/hr) 3. Maintenance infusion is to deliver 0.5 mg/min (15 ml/hr) ~ see Dosing and Administration section. 4. Supplemental boluses of 150 mg over 10 mins if breakthrough arrhythmias occur; no adjustment in the maintenance infusion is made.

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