Protocol deviations in intravenous acetylcysteine therapy for acetaminophen toxicity

Awad, Nadia I.; Geib, Ann-Jeannette; Roy, Akshay; Cocchio, Craig; Bridgeman, Patrick

doi:10.1016/j.ajem.2019.158405

Cited by 6 publications

(2 citation statements)

References 14 publications

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“…The same study group found that two-thirds of patients receiving the three-bag protocol had at least one delay of at least 1 h with a median delay of 90 min [16]. Most recently, Awad et al found administration errors in more than half of their patients receiving IV acetylcysteine [17].…”

Section: Discussionmentioning

confidence: 95%

Adverse reactions in patients treated with the one-bag method of N-acetylcysteine for acetaminophen ingestion

Mullins

O'Grady

et al. 2020

Toxicology Communications

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Acetaminophen (paracetamol) remains the leading pharmaceutical agent in overdoses in North America. The three-bag Prescott protocol for intravenous (IV) acetylcysteine is complex and prone to errors. It has frequent adverse reactions, particularly non-allergic anaphylactoid reactions (NAARs). Over 15 years ago, we adopted a simplified, one-bag protocol using a standard concentration to reduce errors. We report the adverse reactions with this protocol. We used hospital pharmacy records to retrospectively identify patients who received IV acetylcysteine between 12 January 2005 and 20 June 2016. We excluded patients without acetaminophen overdose or with any part of their IV acetylcysteine at an outside hospital. We searched pharmacy records for diphenhydramine or any antiemetic after commencing IV acetylcysteine. We reviewed progress notes for descriptions of nausea, dyspnea, itching/pruritus, or rash. Out of 252 patients receiving IV acetylcysteine, 202 met our inclusion criteria. Thirty-three patients had at least one adverse reaction including nausea in 28 patients and any symptom of NAAR in 8 patients. Twenty-eight patients received an antiemetic. Eleven patients received diphenhydramine (nine for NAAR and two with prochlorperazine). Nausea was the most common adverse reaction. The rate of non-allergic anaphylactoid reactions with the one-bag protocol was 4%. KEYWORDS N-acetylcysteine; adverse events; antidote; acetaminophen MethodsWe conducted a single-center, retrospective cohort study with adherence to the RECORD guidelines [12].

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Section: Discussionmentioning

confidence: 95%

Adverse reactions in patients treated with the one-bag method of N-acetylcysteine for acetaminophen ingestion

Mullins

O'Grady

et al. 2020

Toxicology Communications

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“…A missed diagnosis, delay in treatment, or interruption of acetylcysteine infusion is potentially lethal. A guideline that provides management guidance could optimize patient outcomes, reduce disruption for patients and caregivers, and reduce costs by shortening the length of hospitalization . For complicated scenarios or other questions, PC or clinical toxicology consultation is strongly recommended.…”

Section: Discussionmentioning

confidence: 99%

Management of Acetaminophen Poisoning in the US and Canada

Dart,

Mullins,

Matoushek

et al. 2023

JAMA Netw Open

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ImportanceThe US and Canada currently have no formal published nationwide guidelines for specialists in poison information or emergency departments for the management of acetaminophen poisoning, resulting in significant variability in management.ObjectiveTo develop consensus guidelines for the management of acetaminophen poisoning in the US and Canada.Evidence ReviewFour clinical toxicology societies (America’s Poison Centers, American Academy of Clinical Toxicology, American College of Medical Toxicology, and Canadian Association of Poison Control Centers) selected participants (n = 21). Led by a nonvoting chairperson using a modified Delphi method, the panel created a decision framework and determined the appropriate clinical management of a patient with acetaminophen poisoning. Unique to this effort was the collection of guidelines from most poison centers in addition to systematic collection and review of the medical literature. Comments from review by external organizations were incorporated before the guideline was finalized. The project began in March 2021 and ended in March 2023.FindingsThe search retrieved 84 guidelines and 278 publications. The panel developed guidelines for emergency department management of single or repeated ingestion of acetaminophen. In addition, the panel addressed extended-release formulation, high-risk ingestion, coingestion of anticholinergics or opioids, age younger than 6 years, pregnancy, weight greater than 100 kg, and intravenous acetaminophen use. Differences from current US practice include defining acute ingestion as an ingestion presentation from 4 to 24 hours after overdose was initiated. A revised form of the Rumack-Matthew nomogram was developed. The term massive ingestion was replaced with the term high-risk ingestion and denoted by a specific nomogram line. Other recommendations include specific criteria for emergency department triage, laboratory evaluation and monitoring parameters, defining the role of gastrointestinal decontamination, detailed management of acetylcysteine treatment, associated adverse effects, and stopping criteria for acetylcysteine treatment, as well as criteria for consultation with a clinical toxicologist. Finally, specific treatment considerations, including acetylcysteine dosing, fomepizole administration, and considerations for extracorporeal elimination and transplant evaluation, were addressed.Conclusions and RelevanceThis qualitative study provides a consensus statement on consistent evidence-based recommendations for medical, pharmacy, and nursing education and practice to optimize care of patients with acetaminophen poisoning.

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Intravenous Acetylcysteine: What Should Replace the Prescott “Three-Bag” Protocol?

Nguyen,

Mullins

2024

J. Med. Toxicol.

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Protocol deviations in intravenous acetylcysteine therapy for acetaminophen toxicity

Cited by 6 publications

References 14 publications

Adverse reactions in patients treated with the one-bag method of N-acetylcysteine for acetaminophen ingestion

Adverse reactions in patients treated with the one-bag method of N-acetylcysteine for acetaminophen ingestion

Management of Acetaminophen Poisoning in the US and Canada

Intravenous Acetylcysteine: What Should Replace the Prescott “Three-Bag” Protocol?

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