N-Acetyl cysteine (NAC) infusion instructions The standard administration of NAC is a 2 stage infusion (recently changed from 3 stage infusion) giving a total dose of 300 mg/kg:ĭose calculated based on actual body weight. NAC can be discontinued if both paracetamol concentrations are below the treatment line and are declining If the initial paracetamol concentration is below the line in the nomogram then NAC should be continued, and another paracetamol concentration obtained 4 hours after the initial concentration.If this concentration is above the treatment line in the nomogram then the full 20 hour infusion of NAC is required An initial paracetamol concentration should be measured 4 hours post ingestion or immediately if presentation is >4 hours after ingestion.NAC should be commenced in any patient who reports ingestion of >200 mg/kg or 10 g of sustained release paracetamol.Multiple supratherapeutic paracetamol ingestion Nomogram for acute single dose paracetamol poisoning For IV paracetamol medication errors consult a toxicologist.Consult a toxicologist in cases of very large dose ingestion (>30 g) or if initial paracetamol concentration very high (ie ≥double the nomogram value).>100 mg/kg/day ingested over a 72 hour period.>150 mg/kg/day (or 6 g) ingested over a 48 hour period.>200 mg/kg (or 10 g) ingested over a 24 hour period.There is little evidence to guide management in repeated supratherapeutic doses. Potential toxicity should be assessed and a toxicologist consulted when:.Delaying NAC administration beyond 8 hours post ingestion is associated with a progressive increased risk of liver injury.Patients who present >8 hours after a toxic ingestion (>200 mg/kg) or after an ingestion associated with symptoms of toxicity (RUQ pain or tenderness, nausea, vomiting) should be commenced on NAC immediately. The decision to continue or cease NAC is then based on the paracetamol concentration.It is safe to wait for the paracetamol concentration to decide on the need for NAC in all cases that present within 8 hours of ingestion AND where a paracetamol concentration result will be available for interpretation within 8 hours of ingestion.There is no benefit in measuring paracetamol concentration earlier than 4 hours post ingestion.Serum paracetamol concentration at (or as soon as possible after) 4 hours post ingestion determines the need for N-acetyl cysteine (NAC) administration (see.Signs of fulminant hepatic failure and coagulopathy can occur later than this.In untreated or undertreated cases, signs of hepatotoxicity and hepatic failure usually take 48–72 hours to develop and may include hypotension and encephalopathy.Right upper quadrant tenderness may begin to develop subsequently.Occasionally they complain of nausea, vomiting, pallor and diaphoresis.Most patients who present within 24 hours of ingestion are asymptomatic.If possible, determine the exact name and tablet sizeĬalculate the maximum possible dose per kgĬonsider the possibility of co-ingestions, either accidental or deliberate Examination Any child whose developmental age is inconsistent with accidental poisoning as non-accidental poisoning should be consideredįorm: syrup, immediate or modified-release tablets.
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