George P Bailey1,2, Javad Najafi3, Muhammad E M O Elamin3, W Stephen Waring4, Simon H L Thomas3,5, John R H Archer1,6, David M Wood1,6, Paul I Dargan7,8. 1. Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK. 2. Emergency Department, St Mary's Hospital, Imperial College NHS Trust, London, UK. 3. Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK. 4. York Teaching Hospital NHS Foundation Trust, York, UK. 5. Medical Toxicology Centre, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK. 6. Faculty of Life Sciences and Medicine, King's College London, London, UK. 7. Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK. paul.dargan@gstt.nhs.uk. 8. Faculty of Life Sciences and Medicine, King's College London, London, UK. paul.dargan@gstt.nhs.uk.
Abstract
BACKGROUND: The licensed intravenous acetylcysteine regimen for treating paracetamol overdose in most countries uses three separate infusions over 21 h. This complex regimen, requiring different infusion concentrations and rates, has been associated with administration errors. The aim of the present study was to assess the extent of administration delays occurring during this acetylcysteine regimen. METHOD: A 6-month retrospective observational study was conducted at three English teaching hospitals with clinical toxicology services from October 2014. Patients aged 16 years and over, treated with intravenous acetylcysteine for paracetamol overdose, were included. The start times for infusions were recorded and the delays compared with the prescribed infusion times were calculated. Anaphylactoid reactions, intravenous cannula problems, overdose intent and smoking status were recorded to assess their contribution to delays. RESULTS: From 263 cases identified, 198 met the study inclusion criteria. The median time between the start of infusions 1 and 3 was delayed from the intended 5 h by a median (interquartile range) of 90 (50-163) min, with 135 (68%) cases delayed by more than 1 h. Significantly longer delays were observed in patients with anaphylactoid reactions [median delay 267 (217-413) min, n = 8] and accidental/supratherapeutic overdose [median delay 170 (95-260) min, n = 29]. There were no significant differences between smokers and nonsmokers, or for patients with intravenous cannula problems. CONCLUSION: Long delays were identified during the three-infusion acetylcysteine regimen for the treatment of paracetamol overdose. These were of clinical significance and could lead to periods of subtherapeutic plasma acetylcysteine concentrations and potentially avoidable hepatotoxicity, as well as delaying hospital discharge.
BACKGROUND: The licensed intravenous acetylcysteine regimen for treating paracetamoloverdose in most countries uses three separate infusions over 21 h. This complex regimen, requiring different infusion concentrations and rates, has been associated with administration errors. The aim of the present study was to assess the extent of administration delays occurring during this acetylcysteine regimen. METHOD: A 6-month retrospective observational study was conducted at three English teaching hospitals with clinical toxicology services from October 2014. Patients aged 16 years and over, treated with intravenous acetylcysteine for paracetamoloverdose, were included. The start times for infusions were recorded and the delays compared with the prescribed infusion times were calculated. Anaphylactoid reactions, intravenous cannula problems, overdose intent and smoking status were recorded to assess their contribution to delays. RESULTS: From 263 cases identified, 198 met the study inclusion criteria. The median time between the start of infusions 1 and 3 was delayed from the intended 5 h by a median (interquartile range) of 90 (50-163) min, with 135 (68%) cases delayed by more than 1 h. Significantly longer delays were observed in patients with anaphylactoid reactions [median delay 267 (217-413) min, n = 8] and accidental/supratherapeutic overdose [median delay 170 (95-260) min, n = 29]. There were no significant differences between smokers and nonsmokers, or for patients with intravenous cannula problems. CONCLUSION: Long delays were identified during the three-infusion acetylcysteine regimen for the treatment of paracetamoloverdose. These were of clinical significance and could lead to periods of subtherapeutic plasma acetylcysteine concentrations and potentially avoidable hepatotoxicity, as well as delaying hospital discharge.
Authors: Janice M Pettie; Margaret A Dow; Euan A Sandilands; H K Ruben Thanacoody; D Nicholas Bateman Journal: Emerg Med J Date: 2011-05-11 Impact factor: 2.740
Authors: George P Bailey; Javad Najafi; Muhammad E M O Elamin; W Stephen Waring; Simon H L Thomas; John R H Archer; David M Wood; Paul I Dargan Journal: Br J Clin Pharmacol Date: 2016-08-10 Impact factor: 4.335
Authors: D Nicholas Bateman; James W Dear; H K Ruben Thanacoody; Simon H L Thomas; Michael Eddleston; Euan A Sandilands; Judy Coyle; Jamie G Cooper; Aryelly Rodriguez; Isabella Butcher; Steff C Lewis; A D Bastiaan Vliegenthart; Aravindan Veiraiah; David J Webb; Alasdair Gray Journal: Lancet Date: 2013-11-28 Impact factor: 79.321
Authors: George P Bailey; Javad Najafi; Muhammad E M O Elamin; W Stephen Waring; Simon H L Thomas; John R H Archer; David M Wood; Paul I Dargan Journal: Br J Clin Pharmacol Date: 2016-08-10 Impact factor: 4.335
Authors: Adam McCulloch; Asif Sarwar; Tom Bate; Dave Thompson; Patrick McDowell; Qamar Sharif; Elizabeth Sapey; Adam Seccombe Journal: Digit Health Date: 2020-10-29