Hepatic Dysfunction in Patients Receiving Intravenous Amiodarone

Evaluation of the effect of small single intravenous dose of amiodarone on the prevention of arrhythmias in patients who underwent coronary artery bypass graft surgery: A randomized controlled trial

Background

Atrial fibrillation (AF) is the most frequent arrhythmia after cardiac surgery causing a range of clinical symptoms and treatments that develop in around one-third of coronary artery bypass surgery patients. We aimed to evaluate the effect of Amiodarone in preventing arrhythmia in patients undergoing coronary artery bypass surgery.

Method

In this double-blind randomized clinical trial, 60 patients candidate for coronary artery bypass surgery above the age of 18 were included and randomly divided into two groups of intervention, receiving an infusion of Amiodarone (3 mg/kg) 10 min (in 100 cc Normal saline) before declamping of the aorta, and a control group, receiving 100 cc of saline 10 min before declamping of the aorta. The patient's demographic, clinical features, and hospital and clinical course were recorded.

Results

After undergoing operation, 22 (36.67%) of patients were developed arrhythmia. The Amiodarone group demonstrated significantly lower reperfusion ventricular fibrillation (RVF) rates (26.7% vs. 70%; p = .001) and AF occurrence (13.3% vs. 60%; p < .001) during the initial 24 h after surgery compared to the placebo group. There was no significant difference between the two groups regarding the need for D/C shock after removing the aortic clamp. (p = .117) Furthermore, the intensive care unit stay among the amiodaron group was significantly lower than the control group (2.43 vs. 3.07 days; p = .013).

Conclusion

The predictive properties in the administration of single intravenous low-dose Amiodarone 10 min before the declamping of the aorta can significantly lower the rates of RVF and AF after coronary artery bypass grafting, while also decreasing hospitalization duration.

A Rare Case of Intravenous Amiodarone Toxicity

Amiodarone is a highly effective treatment for life-threatening supraventricular and ventricular arrhythmias, namely in the setting of acutely decompensated heart failure. However, it could be associated with several serious adverse effects both in long-term oral therapy and in short-term use of intravenous (IV) preparation, including shock and liver injury. We report an unusual case of life-threatening refractory hypotension associated with acute hepatitis and renal failure a few hours after initiation of IV amiodarone. A 70-year-old man was admitted to the emergency department (ED) with dyspnea, chest discomfort, and a non-productive cough. Physical examination and complementary diagnostic tests helped diagnose acutely decompensated heart failure due to atrial fibrillation (AF) with a rapid ventricular response, and IV amiodarone was started. A few hours after initiating this drug, the patient developed hypotension with the need for inotropic therapy, acute elevation of amino transaminases, and renal failure. Renal function and liver transaminases returned to baseline after discontinuing amiodarone. A Roussel Uclaf Causality Assessment Method (RUCAM) score of 5 identifies our patient`s acute hepatitis as a possible adverse drug reaction. Refractory hypotension and liver injury with acute hepatitis after a short-term IV amiodarone therapy are extremely rare with few previously reported cases. Therefore, it is very important to perform continuous hemodynamic monitoring of the patient and liver function monitorization during short-term IV administration of this drug because these complications can be potentially fatal. A high index of suspicion is the key to functional organic recovery.

Acute Multi-Organ Toxicity During 24-Hour Dosing of Intravenous Amiodarone: A Case Report

We present a unique case of a 60-year-old male with congestive heart failure who was admitted for a pre-syncopal episode and found to be in atrial fibrillation with rapid ventricular response (RVR). In order to effectively rate control the patient, he was administered an amiodarone bolus and intravenous (IV) infusion over 24 hours, along with a single oral 200 mg dose the following day. The patient subsequently developed acute hepatotoxicity along with features of acute kidney injury (AKI), pulmonary distress, and leukocytosis. After ruling out other etiologies for acute liver, pulmonary, and kidney injury, amiodarone-induced multi-organ toxicity was suspected and amiodarone was discontinued. Within hours of amiodarone discontinuation, the patient’s clinical status and organ function improved remarkably. In the setting of a patient being treated with IV amiodarone and presenting with sudden signs of dyspnea, acute elevation of transaminases and AKI within one to two days of initial dosing, acute amiodarone-induced organ toxicity should be considered.

Hyperammonemic Encephalopathy and Lipid Dysmetabolism in a Critically Ill Patient After a Short Course of Amiodarone

The case is reported of a 39-year-old severely obese woman who developed acute metabolic disorders after the administration of a short course of intravenous amiodarone. The main biological features were hypertriglyceridemia, hypoglycaemia, hyperlactatemia and hyperammonemia; all were reversible after amiodarone discontinuation. There was an associated rise in liver enzymes. However, the influence of co-factors on these metabolic disorders, such as acquired carnitine deficiency, severe obesity, a long-term course of pancreatitis, and abdominal infections, could not be excluded.

Acute liver failure with amiodarone infusion: A case report and systematic review

WHAT IS KNOWN AND OBJECTIVE

Amiodarone, a commonly used class III antiarrhythmic agent notable for a relatively long half-life of up to 6 months and its pronounced adverse effect profile, is used for both acute and chronic management of cardiac arrhythmias. Chronic use of amiodarone has been associated with asymptomatic hepatotoxicity; however, acute toxicity is thought to be uncommon. There are only six reported cases of acute liver failure (ALF) secondary to amiodarone. In all these cases the outcome of death during the same hospitalization resulted. We aimed to report the only case of acute liver failure secondary to amiodarone infusion in the existing literature where the patient survived.

CASE SUMMARY

A 79-year-old woman admitted with atrial flutter was being treated with intravenous (IV) amiodarone when she abruptly developed coagulopathy, altered mental status and liver enzyme derangement. She was diagnosed with acute liver failure (ALF) secondary to an amiodarone adverse drug reaction, with a calculated score of seven on the Naranjo adverse drug reaction probability scale. Amiodarone was immediately withheld, and N-acetylcysteine (NAC) was initiated. Clinical improvement was seen within 48 hours of holding the drug and within 24 hours of initiating NAC. On post-hospital follow-up visit she was reported to have complete recovery.

WHAT IS NEW AND CONCLUSION

This report emphasizes the importance of monitoring liver enzymes and mental status while a patient is being administered IV amiodarone. N-acetylcysteine administration may have possibly contributed to the early and successful recovery from ALF in our patient. To date, she is the only patient in the existing literature who has been reported to survive ALF secondary to amiodarone administration.