Amio question

[dalmain]

Just wondering. At my place of work I noticed that we don't carry 50 ml of D5W, but we have 100 ml of D5W and 250 ml's. So if I had to use Amiodarone and wanted to hang a maintenance drip. Could I just mix 300mg of Amiodarone into the 100 ml of D5W or 600mg of Amiodarone into the 100 ml of D5W? But I don't think we even carry that much of the drug to begin with. They would probably fire me.

 

[Handsome Robb]

Are you talking about a maintenance drip post loading dose or are you talking about the 150 mg loading dose we give as a drip over 10 minutes? Often mistaken as a maintenance dose.

 

[MonkeyArrow]

Why are you guys even starting maintenance drips? Are your transport times that far out that you need to start them? For what it counts (which is very very very little), I say you let the nice nurses at the hospital start the drip .

But to answer your question, assuming you mean 300 into 50 and 600 into 100, that seems like a high dosage for a maintenance drip. I have learned to mix 1000mg in 500mL and to run it at 15 mL/hr (15 micro drops/minute).

 

[Rialaigh]

Why are you guys even starting maintenance drips? Are your transport times that far out that you need to start them? For what it counts (which is very very very little), I say you let the nice nurses at the hospital start the drip .

But to answer your question, assuming you mean 300 into 50 and 600 into 100, that seems like a high dosage for a maintenance drip. I have learned to mix 1000mg in 500mL and to run it at 15 mL/hr (15 micro drops/minute).

I believe local protocol here says if amio was the drug used to convert (whether you gave 150 over 10 minutes or 300 push for pulseless) then you hang 150 in whatever you want and run it over an hour after conversion.

 

[NomadicMedic]

Over an hour? If we dose them with 300 (or none!) and achieve ROSC following a VF/VT arrest, they get 150 over 10 minutes. (Also known as put it in a 100ml bag and run it wide open)

 

[SandpitMedic]

An hour? Yeah it's supposed to be over 10 minutes.

Here it is 150mg Amio in 50mL NS over 10 minutes. That's if only if either a) they are in a stable monomorphic Vtach b) the pt is unstable and cardio version is unsuccessful(after 1st shock, and keep shocking) or C) 300mg IV push during CPR after the 3rd round of CPR/Dfib if the PT is in a shockable rhythm.

No "maintenance" doses here.
The goal is to convert. Most transports are short around here, I'd say 10-20 minutes. I suppose in an outlying area, that is what medical control is for. Get some on-line orders and transport.

 

[usalsfyre]

Amio does bad things to plastic. True maintenance infusions (360 over 8 hours followed by 540 over 16) are hung in glass. 150mgs over 10 minutes is probably fine, but I don't know that I'd push it much more than that.

 

[SandpitMedic]

Does it now? Never heard of that, that's interesting knowledge.

Source on amio vs plastic?

I'm not questioning/challenging your response; I'm genuinely interested in this since I've never heard that before.

 

[Carlos Danger]

Every amio infusion I've ever seen was in a normal PVC bag.

 

[Handsome Robb]

Every amio infusion I've ever seen was in a normal PVC bag.

I was thinking that as well.

 

[triemal04]

A "true maintenance infusion" of amiodarone following a loading dose is 1mg/min for 6 hours (60mg/hr) followed by 0.5mg/min for 18 hours (30mg/hr). This ignores that a fair amount of people will not be able to tolerate that much and get less. And that the half-life is so long that the time when this is needed likely well beyond when most paramedics will have turned over care.

Amiodarone in the original mix does not "do bad things to plastic." A very small amount of it get's absorbed into the PVC in the bags and drip-sets. Is it enough to really matter? Not really. The even better news is that there is a new formula that has FDA approval that not only is completely compatible with PVC, but also does not contain polysorbate; unfortunately it'll be trademarked for awhile, so I wouldn't expect to see it get much widespread use.

This is basic pharmacology that any paramedic or paramedic student should have learned in school.

 

[usalsfyre]

Amio does bad things to plastic. True maintenance infusions (360 over 8 hours followed by 540 over 16) are hung in glass. 150mgs over 10 minutes is probably fine, but I don't know that I'd push it much more than that.

I can't think think of an amio infusion I've transported that's been in plastic in six years of CCT.

 

[triemal04]

And in all those "6" years of "CCT" how many times was the tubing used PVC free, and how many times was it the standard tubing for the pump that was being used?

If you also wouldn't mind elaborating on the "bad things" that amiodarone does to plastic...

 

[medicsb]

As mentioned, amiodarone (at least in prior formulations), was absorbed by PVC. However, it is a slow process with negligible change in dose during the first few hours. The amount absorbed depend in part upon amio concentration and infusion rate. Basically, glass is not needed in the prehospital setting unless you actually have multi-hour transports.

 

[NPO]

"The loss of amiodarone from i.v. admixtures to flexible polyvinyl chloride (PVC) infusion bags and i.v. administration sets was studied. Admixtures containing amiodarone hydrochloride 600 micrograms/mL and either 5% dextrose injection or 0.9% sodium chloride injection were stored at room temperature in glass bottles (both with and without contact of the drug solution with the rubber bottle closure), in flexible PVC bags, or in rigid PVC bottles. After 120 hours, the contents of each flexible PVC bag were emptied and replaced by methanol, which was allowed to remain in the bag for an additional 120 hours and was then analyzed for amiodarone content. To determine availability of amiodarone after infusion through a 1.8-m PVC i.v. administration set, solutions stored in glass containers were run through the set at 0.5 mL/min for 90 minutes. Samples of drug solutions were collected at appropriate intervals and analyzed by a stability-indicating high-performance liquid chromatography (HPLC) assay. Admixtures containing 0.9% sodium chloride injection were not stable; visual incompatibility was evident after 24 hours of storage in glass bottles, and no further testing was performed. In admixtures containing 5% dextrose injection that were stored in 50-mL flexible PVC bags, 60% of the initial amiodarone concentration remained after 120 hours; approximately half of the lost drug was recovered with the methanol. In effluent collected from the PVC administration set, 82% of the initial amiodarone concentration remained. Amiodarone concentrations did not decrease appreciably, after storage in glass or rigid PVC bottles, indicating that drug loss was probably affected by the plasticizer, di-2-ethylhexyl phthalate."

http://www.ncbi.nlm.nih.gov/m/pubmed/4083289/

 

[18G]

Our protocols are written to start amiodarone drips for VT after conversion at the standard 1mg/min. It doesn't really matter the concentration you mix. We carry 450mg total of amiodarone.

I personally would do 150mg/250mL which at 1mg/min = 100mL/hr. That would last you 2.5hrs.

You could also do 300mg/500mL which remains at 100mL/hr.