Amiodarone induced thrombophlebitis

Postoperative atrial fibrillation prophylaxis using a novel amiodarone order set

Background

Studies have demonstrated that chemoprophylaxis following anatomic lung resection can reduce post-operative atrial fibrillation (POAF). However, it is unclear if non-anatomic wedge resection warrants prophylaxis, as previously published rates vary widely. The primary goal of this study was to assess an institutional rate of POAF following anatomic resections with implementation of a novel amiodarone administration regimen compared to wedge resections without prophylaxis.

Methods

We performed a retrospective cohort study of a prospectively maintained database and compared anatomic and wedge lung resection patients from 1/2015 to 4/2018. During the study period, a previously unpublished amiodarone order set consisting of a 300 mg IV bolus followed by 400 mg tablets TID ×3 days was administered to anatomic resection patients ≥65 who met criteria. Wedge resection patients were not intended to receive amiodarone prophylaxis. The primary outcome was POAF incidence. Risk factors for developing POAF were assessed.

Results

A total of 537 patients met inclusion where 56% underwent anatomic resection and 44% wedge resection. Overall, 5.4% of patients experienced POAF. There was a significant reduction in post-anatomic resection POAF as compared to historic rates without prophylaxis (9.3% vs. 20.3%, P<0.001). A single wedge resection patient (0.4%) developed POAF. On multivariable analysis, the only independent POAF risk factor was age ≥65 (OR: 5.41, 95% CI: 1.47-19.85).

Conclusions

Administration of our novel amiodarone order set reduces POAF after anatomic resection; however, POAF following wedge resection is too rare to warrant chemoprophylaxis.

Phlebitis in Intravenous Amiodarone Administration: Incidence and Contributing Factors

BACKGROUND

Intravenous amiodarone is the gold-standard treatment for arrhythmias, but phlebitis is a common adverse effect.

OBJECTIVES

To determine the incidence and contributing factors of amiodarone-induced phlebitis and examine phlebitis severity.

METHODS

A systematic review was conducted of articles published before February 2016 in the Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, MEDLINE, Embase, Web of Science, and gray databases (Bielefeld, Lenus, EUGrey, RIAN, and DART). All studies in which amiodarone-induced phlebitis was a primary or secondary outcome were included. Meta-analysis was not appropriate because of study heterogeneity. Studies of the same contributing factors were analyzed together.

RESULTS

In the 20 included studies, phlebitis incidence ranged from 0% to 85%. Increasing the infusion concentration from 1.2 mg/mL to 1.8 mg/mL increased the phlebitis rate (P < .001). Total amiodarone doses greater than 1 g resulted in higher phlebitis rates than did doses less than 0.45 mg (P < .001). Most infusion durations and rates were not correlated with phlebitis incidence. However, phlebitis incidence was lower with bolus administration than with longer infusions (P = .002). The use of in-line filters and nursing guidelines significantly reduced phlebitis rates (P < .001) and phlebitis severity. The most common phlebitis severity grades, in descending order, were 0, 1, 2, 3, and 4.

CONCLUSIONS

Understanding factors that increase the risk of amiodarone-induced phlebitis can guide better practice. In-line filters and nursing guidelines should always be implemented when administering intravenous amiodarone. Increased surveillance is required when higher dosages and concentrations are used.

Intravascular thrombophlebitis related to the peripheral infusion of amiodarone and vancomycin

Patients on a telemetry unit experienced an increase in thrombophlebitis in 2004. The purpose of this research was to determine if peripheral IV amiodarone and vancomycin influenced the incidence of thrombophlebitis in an adult cardiothoracic population. Amiodarone phlebitis rates range up to 27%. In December 2004, Pharmacy diluted the amiodarone concentration to 600 mg/500 ml. By 2005, data demonstrated a consistent decrease in the incidence of thrombophlebitis. However, related to institutional policies and patient safety concerns, the amiodarone infusion concentration was reversed back to 900 mg/500 ml in October 2005. Thrombophlebitis increased after the return to a more concentrated amiodarone IV solution. Vancomycin infusion administration did not change during this time period. A retrospective chart review and observational, before and after study, demonstrated a correlation between amiodarone concentration and the incidence of thrombophlebitis. Vancomycin infusions appeared to prevent peripheral thrombophlebitis in the study population. Data was compelling and resulted in the institution standardizing the more dilute amiodarone IV concentration.