Amiodorone bolus, biphasic cardioverting

[OutdoorLovinRN]

I'm precepting as a new grad nurse. I had a pt today who went into a-fib during my shift. His HR was 140-160 with MAP of 57-60 (down from 60-70 prior). His O2 sat was decreasing to 90 from 100 without any changes on vent settings. MD made decision to cardiovert. The MD told me she was going to wait for the amiodorone bolus before cardioverting. I administered 150 mg undiluted IV push over 2-3 min into the central line. We cardioverted a couple minutes later with biphasic 120,150,200,200 to no effect. Then we started amiodorone infusion 1 mg/min (150 mg/in 100 D5W). We also started dilt and dopamine. Pressures came up, HR went down, and after 2 hours he was sinus tach again (as he had been previously). O2 sat went up a little too.

I read that you're supposed to give the amiodorone bolus of 150 mg mixed in 100 mL D5w over 10 min. Whereas, I gave it undiluted IV push over 2-3 minutes. Would the cardioversion have been more successful possibly if I had administered the bolus correctly? Was I even wrong to give the bolus the way that I did? Could I have caused v-tach/v-fib by pushing it undiluted so fast?

As to the cardioversion, with the biphasic machines, shouldn't you be able to cardiovert at less joules than you defibrrilate (this was my first cardioversion..but I thought someone had told me that you can start with less joules for cardioversion)? (although our pt did weigh 100 kg).

Thanks!

[EricJRN, MSN, RN]

I'm not sure of the specific effect of the rapid administration of Amio, but I think you're right to be concerned about the energy levels used in the cardioversion. Although it's been a while since I worked with a biphasic machine, I think the biphasic energy levels for synchronized cardioversion should be a lot lower than that. For atrial fib, you would start lower than 120 (70 or 100?) even with monophasic machines if I'm not mistaken.

[Dinith88]

I'm precepting as a new grad nurse. I had a pt today who went into a-fib during my shift. His HR was 140-160 with MAP of 57-60 (down from 60-70 prior). His O2 sat was decreasing to 90 from 100 without any changes on vent settings. MD made decision to cardiovert. The MD told me she was going to wait for the amiodorone bolus before cardioverting. I administered 150 mg undiluted IV push over 2-3 min into the central line. We cardioverted a couple minutes later with biphasic 120,150,200,200 to no effect. Then we started amiodorone infusion 1 mg/min (150 mg/in 100 D5W). We also started dilt and dopamine. Pressures came up, HR went down, and after 2 hours he was sinus tach again (as he had been previously). O2 sat went up a little too.

I read that you're supposed to give the amiodorone bolus of 150 mg mixed in 100 mL D5w over 10 min. Whereas, I gave it undiluted IV push over 2-3 minutes. Would the cardioversion have been more successful possibly if I had administered the bolus correctly? Was I even wrong to give the bolus the way that I did? Could I have caused v-tach/v-fib by pushing it undiluted so fast?

As to the cardioversion, with the biphasic machines, shouldn't you be able to cardiovert at less joules than you defibrrilate (this was my first cardioversion..but I thought someone had told me that you can start with less joules for cardioversion)? (although our pt did weigh 100 kg).

Thanks!

Usually, iv-push amio load is reserved for coding patients who are down...

If your patient is being electively cardioverted, you're correct it should've been given over 10minutes. The biggest thing with loading someone so rapidly is that it can cause a sudden (and marked) hypotension...which could've made your situation much worse. Another concern is that amio is so prone to foaming up and bubbling. You dont need to worry about inducing vt/vf (if this is listed somewhere as a possible side-effect it's very very unusual).

And as far as your concern about lower energy levels...yes you probably should (according to acls and such) start a little lower, but starting at 120 isnt going to (in practice) make any difference. And besides...starting lower obviously wouldn't have helped your patient as she wouldnt convert after 2 shocks at 200.

At first glance, it seems this doc might have jumped the gun a bit anyway. She could've waited for amio to work...or the cardizem that she eventually resorted to. Instead the patient got electrocuted several times and started on amio and cardizem anyway (which worked in the end).

[OutdoorLovinRN]

I agree about wondering why the MD didn't start the dilt and amiodarone drips and wait a little while before cardioverting. I was going to ask the MD, but wasn't sure if it was a silly question. I had wondered if maybe the MD was concerned about the pt's MAP, and if that's why she elected to try cardioverting first. Thanks for letting me know about possibly hypotension with amiodarone bolusing too fast. Next time I will run it over 10 minutes if logistically possible. I'm thankful that my pushing it didn't precipitiously lower his BP the other day.

Another question about cardioversion, is would it be better to give the pt midazolam than ativan prior to doing it? Does midazolam create better amnesia of the event? For this pt, I gave 4 mg morphine, and that's it. But he had had ativan ordered PRN. I didn't give it b/c I wasn't sure if it'd lower his BP even more....but later, when I asked the MD if I could have administered the ativan also, she said it would have been fine (didn't ask about the possibility of versed, as the pt didn't have it on his PRN list). I'm just asking b/c this pt jumped halfway off the bed all four times. Although he was kind of out of it....I think the shocks was a traumatic surprise and I felt bad for him. One time his leg went way up in the air and slammed down on the side rail. It was awful to see. And all for naught too...since we didn't break him out of the afib.