According to the 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation report, IV amiodarone is an appropriate alternative for rate control and may facilitate the conversion to sinus rhythm. However, this guideline fails to caution about the potential for drug-induced phlebitis associated with the use of the IV formulation of amiodarone. The incidence of amiodarone-induced phlebitis may be as high as 85%.

Guidelines to prevent amiodarone-induced phlebitis have been proposed for hospitals in Norway. Among the recommendations are to administer concentrations of <1.2 mg/mL via peripheral IV catheters (PIVC), with higher concentrations administered via a central venous catheter (CVC); to only dilute amiodarone with 5% glucose; to flush the PIVC with glucose prior to infusion; to administer amiodarone through an infusion pump; to utilize an in-line filter to prevent crystallization; to use a 22-gauge needle as opposed to larger PIVCs (18-20 gauge) to possibly minimize the rate phlebitis; and to avoid the elbow as an administration site.

A prospective observational study was conducted to determine the incidence of IV amiodarone–induced phlebitis, to describe adherence to clinical practice guidelines, and to determine how formulation/patient characteristics were distributed between those with and without phlebitis in four clinics at a university hospital in Norway. Patients aged 18 years or older who received amiodarone either via a PIVC or CVC during March to May 2021 were included in the study. Study patients were identified by two research nurses who assisted with data collection and study enrollment. A standardized data abstraction form was utilized. The PIVC-miniQ, a validated tool containing four main assessment areas, was used to screen for phlebitis and to determine adherence to clinical practice guidelines. The first area of the PIVC-miniQ contains nine items related to phlebitis-related signs and symptoms; the second area has five items pertaining to PIVC dressing and IV connection related to the PIVC failure. The third section has one item pertaining to documentation, and the fourth part has one item referring to the indication for PIVC.

In total, 124 patients with a mean age of 71 years received parenteral amiodarone. The primary indication for use of amiodarone was atrial fibrillation. Of these patients, 86 (69%) received amiodarone via a PIVCC. Patients who received amiodarone via a PIVC versus a CVC were more often maintained on the drug for >24 hours (21% vs. 3%, respectively). Among those who received amiodarone via a PIVC, 44% developed phlebitis as evidenced by >2 signs of phlebitis based on the PIVC-miniQ. Among the most common signs and symptoms of phlebitis were pain, tenderness, redness, and swelling at the injection site. The incidence of phlebitis increased as the infusion time increased with 75% of patients developing phlebitis after receiving amiodarone for 25 to 48 hours, and all patients developing phlebitis when the infusion time went past 48 hours. While 40% of phlebitis was observed within the first 24 hours of amiodarone administration, this increased in the postinfusion phase.

While adherence based on concentration was appropriate for the majority of patients (i.e., concentrations of 1.2 mg/mL administered via the PIVC and concentrations of 3 mg/mL given via CVC), an in-line filter was only used in four out of five infusions. Further, in almost 30% of patients, the PIVC was not flushed with glucose prior to starting the infusion increasing the risk of drug crystallization. Only 15% of the PIVCs were 22 gauge, the recommended size. Most PIVCs (35%) were placed in the elbow, which is not a recommended site of administration. The best practices of utilizing a 22-gauge PIVC and administering amiodarone in the forearm were only observed in 5% of cases.

Pharmacists can play a major role in educating other healthcare professionals on strategies to minimize amiodarone-induced phlebitis. This can help prevent patient discomfort and reduce the risk of endocarditis secondary to PIVC-induced phlebitis-related bloodstream infections.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

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