The nurse comes to inform your junoir that she made a mistake and gave a 5 years old child who is 15 Kg the whole 1 gram IV paracetamol instead of 250 mg as prescribed.
Your junoir thinks it is still within non toxic dose as it is less than 150mg/kg . He also want to send a 4 hour paracetamol level and decides based on Rumack normogram.
Q1.Do you agree with your junoir plan?
Q2.What will be the indications to treat with NAC after IV paracetamol overdose?
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Oops Wrong Dose Cont'!!
Thanks all for your comments
The comments it seems more for oral APAP , where the case is for IV APAP
Experience with patients with IV APAP overdose is limited as well as guidelines.
The time to peak of the IV acetaminophen formulations are immediate (< 15 minutes). In adults, peak [APAP] after a 1-g infusion is approximately 30 mcg/mL and after a 2-g infusion is approximately 75 mcg/mL with a large range of 31 to 161 mcg/mL .
Intravenous administration of APAP leads to a higher initial [APAP] and higher bioavailability than oral use and should theoretically expose the liver to less APAP.
Hepatotoxicity and liver failure have been described after single erroneous supra-therapeutic doses of 75 to 150 mg/kg. These errors most commonly occur in young children and include 10 fold dosing errors.
Cases of hepatotoxicity and liver failure have occurred in patients whose [APAP] was well below the treatment line. Cases of hepatotoxicity with liver failure are reported after repeated therapeutic dosing in severely catabolic patients over 3-5 days
*Although the nomogram is extensively studied in patients with oral APAP ingestion, there is no evidence for its use in those with IV overdose.
* Due to limited data and that iatrogenic errors are usually quantifiable, it seems reasonable to treat a patient with NAC if he or she was exposed to more than 60 mg/kg of IV APAP in a single dose and to treat until the [APAP] is undetectable.
It is also reasonable to treat patients receiving multiple therapeutic doses of IV APAP with NAC if there is evidence of hepatotoxicity .
References:
1- Goldfrank’s Toxicologic Emergencies 11td edition
Getting APAP Levels
Pre-4 hour vs 4-hour level
Getting an APAP level 1 to 4 hours after ingestion may be helpful only to exclude ingestion of APAP (that is, if the level is zero).
Obtain a 4-hour level (or later, up to 24 hours) to get estimated peak absorption (that is, if time of ingestion is certain).
Using APAP Rumack-Matthew Nomogram
The Rumack-Matthew nomogram is used to determine the risk of APAP-induced hepatoxicity after a single acute ingestion only (not for chronic or repeated ingestions).
Serum concentrations above the treatment line indicate the need for N-acetylcysteine (NAC) therapy.
The treatment line starts at 150 mcg/mL at 4 hours post-ingestion.
N-acetylcysteine (NAC) Administration:
Administer if toxic level detected as defined by Rumack–Matthew nomogram. NAC virtually 100% hepatoprotective if initiated within 8 hr of an acute overdose NAC available in oral form or IV form
<8 hr postingestion: Check APAP level. Initiate NAC if APAP level will not be available within 8 hr of ingestion and toxic ingestion suspected. Discontinue NAC
if APAP level nontoxic.
≥8 hr postingestion: Initiate NAC immediately if suspected toxic ingestion. Check APAP level. Discontinue NAC if APAP level is nontoxic.
>24 hr postingestion or chronic repeated APAP ingestion Initiate NAC if: Ingestion >150 mg/kg APAP Symptomatic Abnormal hepatic screening panel. Discontinue NAC if APAP falls to nondetectable level and no AST elevation occurs by 36 hr postingestion
- Yes because tere is no benefit in measuring paracetamol concentration earlier than 4 hours post ingestion
- The standard administration of NAC is a 2 stage infusion (recently changed from 3 stage infusion) giving a total dose of 300 mg/kg:
200 mg/kg over 4 hours
100 mg/kg over the next 16 hours
Paracetamol ingestions between 10gm (200mg/kg) and 30gm (500mg/kg) should be treated with standard acetylcysteine infusion
Massive paracetamol overdoses (over 30g) resulting in paracetamol concentrations more than double the nomogram line should be treated with double the dose of acetylcysteine (200 mg/kg) in the second bag of the treatment
Paracetamol levels ≥ triple the nomogram line should be discussed with a clinical toxicologist as they may require higher acetylcysteine doses
- Yes because tere is no benefit in measuring paracetamol concentration earlier than 4 hours post ingestion
- The standard administration of NAC is a 2 stage infusion (recently changed from 3 stage infusion) giving a total dose of 300 mg/kg:
200 mg/kg over 4 hours
100 mg/kg over the next 16 hours
Paracetamol ingestions between 10gm (200mg/kg) and 30gm (500mg/kg) should be treated with standard acetylcysteine infusion
Massive paracetamol overdoses (over 30g) resulting in paracetamol concentrations more than double the nomogram line should be treated with double the dose of acetylcysteine (200 mg/kg) in the second bag of the treatment
Paracetamol levels ≥ triple the nomogram line should be discussed with a clinical toxicologist as they may require higher acetylcysteine doses
I think I agree with his plan