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Vincent F, Thompson J, Gray L, Bradberry S, Sandilands E, Thanacoody R, Tuthill D. Medication errors involving intravenous paracetamol in children: experience from enquiries to the National Poisons Information Service. Arch Dis Child 2024; 109:582-585. [PMID: 38233098 DOI: 10.1136/archdischild-2023-326460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/30/2023] [Indexed: 01/19/2024]
Abstract
INTRODUCTION Children are at higher risk of medication errors due to the complexity of drug prescribing and administration in this patient group. Intravenous (IV) paracetamol overdose differs from overdose by ingestion as there is no enteral absorptive buffering. We provide the first national UK data focusing on paediatric IV paracetamol poisoning. METHODS All telephone enquiries to the National Poisons Information Service between 2008 and 2021 regarding children less than 18 years old in the UK concerning IV paracetamol overdose were extracted from the UK Poisons Information Database (UKPID). Data were analysed using descriptive statistics. RESULTS Enquiries were made concerning 266 children, mostly involving children under the age of 1 year (n=145; 54.5%). Acute and staggered overdoses were the most frequent types of exposure. Common error themes included 10-fold overdose in 45 cases (16.9%) and inadvertent concomitant oral and IV dosing in 64 cases (24.1%). A high proportion of cases were asymptomatic (87.1%), with many calls regarding overdoses below the treatable dose of 60 mg/kg (41.4%). Treatment with the antidote acetylcysteine was advised in 113 cases (42.5%). CONCLUSIONS Inadvertent IV paracetamol overdose appears to occur more frequently in young children. A significant proportion were calculation errors which were often 10-fold errors. While these errors have the potential for causing serious harm, thankfully most cases were asymptomatic. Errors with IV paracetamol might be reduced by electronic prescribing support systems, better communication regarding administration and consideration of whether other routes are more appropriate.
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Affiliation(s)
| | | | | | | | | | | | - David Tuthill
- Paediatrics, Children's Hospital for Wales, Cardiff, UK
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Deutsch AB, DelBianco JD, Fagan P, Sharpe K, Laskosky J, Koons L, Beauchamp GA, Katz KD. Evaluation of an Intravenous Acetaminophen Protocol in the Emergency Department. Cureus 2024; 16:e52934. [PMID: 38406114 PMCID: PMC10893979 DOI: 10.7759/cureus.52934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/24/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Acute pain is a leading reason for Emergency Department (ED) evaluation, accounting for nearly half of all ED visits. Therefore, providing effective non-opioid analgesics in the ED is critical. Oral acetaminophen (APAP) is commonly administered in the ED but is limited to patients tolerating oral intake. Intravenous (IV) APAP provides significant pain reduction parenterally. The purpose of this quality assessment project was to evaluate the frequency of opioid use in patients receiving IV APAP, the safety of IV APAP, and compliance with an ED IV APAP protocol. METHODS This study included all patients who received IV APAP in the ED of a tertiary care, level I trauma center, during a three-month period. The protocol required ED patients to be NPO (nil per os), 18 years or older, and administered with a single 1000 mg dose. The adverse reactions within 24 hours post-IV APAP, ED length of stay (LOS), and opioid administration within four hours post-IV APAP were assessed. RESULTS Ninety-four patients received IV APAP. All patients received a 1000 mg dose. One patient received more than one dose, but this patient had a 22-hour ED LOS. Two patients received oral medications within one hour of IV APAP (one received an antacid, and the other received carbamazepine and lamotrigine). An opioid was administered to 22 of the 94 (23.4%) patients during the four-hour protocol period. There were no reports of adverse reactions. CONCLUSIONS The results show excellent compliance with the protocol. IV APAP was safe and well-tolerated. Notably, most patients did not receive an opioid within four hours of IV APAP. IV APAP can be safely and effectively utilized as an analgesic and lessen ED opioid use.
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Affiliation(s)
- Aaron B Deutsch
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - John D DelBianco
- Department of Emergency and Hospital Medicine, Division of Medical Toxicology, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - Patrick Fagan
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - Kimberly Sharpe
- Department of Pharmacy, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - Jason Laskosky
- Department of Pharmacy, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - Laura Koons
- Department of Pharmacy, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - Gillian A Beauchamp
- Department of Emergency and Hospital Medicine, Division of Medical Toxicology, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
| | - Kenneth D Katz
- Department of Emergency and Hospital Medicine, Division of Medical Toxicology, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA
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Koppen A, Bekkers CHJ, Slabbers GHPR, de Lange DW, Verkooijen RBT. An intravenous paracetamol overdose in an eight-day-old neonate. Clin Toxicol (Phila) 2023; 61:1063-1064. [PMID: 38085531 DOI: 10.1080/15563650.2023.2289867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/27/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Arjen Koppen
- Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | - Dylan W de Lange
- Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, Utrecht, The Netherlands
- Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robbert B T Verkooijen
- Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, Utrecht, The Netherlands
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Dart RC, Mullins ME, Matoushek T, Ruha AM, Burns MM, Simone K, Beuhler MC, Heard KJ, Mazer-Amirshahi M, Stork CM, Varney SM, Funk AR, Cantrell LF, Cole JB, Banner W, Stolbach AI, Hendrickson RG, Lucyk SN, Sivilotti MLA, Su MK, Nelson LS, Rumack BH. Management of Acetaminophen Poisoning in the US and Canada: A Consensus Statement. JAMA Netw Open 2023; 6:e2327739. [PMID: 37552484 DOI: 10.1001/jamanetworkopen.2023.27739] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023] Open
Abstract
Importance The 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. Objective To develop consensus guidelines for the management of acetaminophen poisoning in the US and Canada. Evidence Review Four 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. Findings The 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 Relevance This 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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Affiliation(s)
- Richard C Dart
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver
| | - Michael E Mullins
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, Missouri
| | | | - Anne-Michelle Ruha
- Banner University Medical Center Phoenix, Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix
| | - Michele M Burns
- Massachusetts/Rhode Island Poison Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Karen Simone
- Northern New England Poison Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Michael C Beuhler
- Northern Carolina Poison Control, Atrium Health, Charlotte
- Department of Emergency Medicine, Wake Forest School of Medicine, Salem, North Carolina
| | - Kennon J Heard
- Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, University of Colorado School of Medicine, Denver
| | - Maryann Mazer-Amirshahi
- MedStar Washington Hospital Center, National Capital Poison Center, Georgetown University School of Medicine, Washington, DC
| | - Christine M Stork
- Upstate New York Poison Center, Upstate Medical University, Syracuse
| | - Shawn M Varney
- South Texas Poison Center, University of Texas Health, San Antonio
| | | | - Lee F Cantrell
- Department of Clinical Pharmacy, University of California San Francisco School of Pharmacy, San Francisco
- California Poison Control System, San Diego Division, University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego
| | - Jon B Cole
- Minnesota Poison Control System, Hennepin Healthcare, University of Minnesota Medical School, Minneapolis
| | | | | | | | - Scott N Lucyk
- Poison and Drug Information Service, University of Calgary Department of Emergency Medicine, Calgary, Alberta, Canada
| | | | - Mark K Su
- New York City Poison Control Center, New York University Grossman School of Medicine, New York
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark
| | - Barry H Rumack
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
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5
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Trebach J, Mahonski SG, Melchert K, Howland MA, Chiang WK. Intravenous Acetaminophen Overdose in an Infant With Toxicokinetic Data. J Pharm Pract 2023; 36:173-175. [PMID: 34080465 DOI: 10.1177/08971900211021286] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CASE REPORT A 12-month-old (former 24 week gestational age), 8.7 kg male was hospitalized after an uneventful colostomy reversal. In the postoperative unit, the patient unintentionally received 1000 mg IV (114.9 mg/kg) acetaminophen instead of the intended 100 mg IV. Serial acetaminophen concentrations were drawn. The patient received IV Nacetylcysteine and ultimately had no adverse outcomes. DISCUSSION This case report adds to the existing literature regarding toxicokinetics of IV APAP in infants. Our patient had a calculated ke of 0.263 h-1, correlating with a half-life of 2.63 hours. Based on current available data, the half-life of IV APAP in infants varies (2.6 to 4.9 hours). The reason for this variation is unknown and further research is needed in this area.
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Affiliation(s)
- Joshua Trebach
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, 12297NYU Grossman School of Medicine, New York, NY, USA.,Department of Health and Mental Hygiene, 12296New York City Poison Control Center, New York, NY, USA
| | - Sarah G Mahonski
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, 12297NYU Grossman School of Medicine, New York, NY, USA.,Department of Health and Mental Hygiene, 12296New York City Poison Control Center, New York, NY, USA
| | - Kristina Melchert
- Department of Pediatrics, Maria Fareri Children's Hospital, 497001Westchester Medical Center Health Network, Valhalla, NY, USA
| | - Mary Ann Howland
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, 12297NYU Grossman School of Medicine, New York, NY, USA.,Department of Health and Mental Hygiene, 12296New York City Poison Control Center, New York, NY, USA.,College of Pharmacy and Health Sciences, St John's University, Queens, NY, USA
| | - William K Chiang
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, 12297NYU Grossman School of Medicine, New York, NY, USA.,Department of Health and Mental Hygiene, 12296New York City Poison Control Center, New York, NY, USA
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6
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Lonati D, Schicchi A, Petrolini VM, Locatelli CA. Comment on accidental intravenous acetaminophen overdose in an infant without development of hepatotoxicity. Clin Toxicol (Phila) 2022; 60:1191-1192. [PMID: 36069778 DOI: 10.1080/15563650.2022.2116338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Davide Lonati
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, University of Pavia, Pavia, Italy
| | - Azzurra Schicchi
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, University of Pavia, Pavia, Italy
| | - Valeria Margherita Petrolini
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, University of Pavia, Pavia, Italy
| | - Carlo Alessandro Locatelli
- Pavia Poison Control Centre - National Toxicology Information Centre - Clinical and Experimental Lab, Toxicology Unit - Istituti Clinici Scientifici Maugeri IRCCS, University of Pavia, Pavia, Italy
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7
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Patel AK, Gai J, Trujillo-Rivera E, Faruqe F, Kim D, Bost JE, Pollack MM. National Intravenous Acetaminophen Use in Pediatric Inpatients From 2011–2016. J Pediatr Pharmacol Ther 2022; 27:358-365. [DOI: 10.5863/1551-6776-27.4.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/17/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
To 1) determine current intravenous (IV) acetaminophen use in pediatric inpatients; and 2) determine the association between opioid medication duration when used with or without IV acetaminophen.
METHODS
A retrospective analysis of pediatric inpatients exposed to IV acetaminophen from January 2011 to June 2016, using the national database Health Facts.
RESULTS
Eighteen thousand one hundred ninety-seven (2.0%) of 893,293 pediatric inpatients received IV acetaminophen for a median of 14 doses per patient (IQR, 8–56). A greater proportion of IV acetaminophen patients were admitted to the intensive care unit (ICU) (14.8% vs 5.1%, p < 0.0001), received positive pressure ventilation (2.0% vs 1.5%, p < 0.0001), had a higher hospital mortality rate (0.9% vs 0.3%, p < 0.0001), and were operative (35.5% vs 12.8%, p < 0.001) than those not receiving IV acetaminophen. The most common operations associated with IV acetaminophen use were musculoskeletal and digestive system operations. Prescription of IV acetaminophen increased over time, both in prescription rates and number of per patient doses. Of the 18,197 patients prescribed IV acetaminophen, 16,241 (89.2%) also were prescribed opioids during their hospitalization. A multivariate analysis revealed patients prescribed both IV acetaminophen and opioids had a 54.8% increase in opioid duration as compared with patients who received opioids alone.
CONCLUSIONS
This is the first study to assess IV acetaminophen prescription practices for pediatric inpatients. Intravenous acetaminophen prescription was greater in the non-operative pediatric inpatient population than operative patients. Intravenous acetaminophen prescription was associated with an increase in opioid duration as compared with patients who received opioids alone, suggesting that it is commonly used to supplement opioids for pain relief.
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Affiliation(s)
- Anita K. Patel
- Department of Pediatrics, Division of Critical Care Medicine DC (AKP, MMP), Children's National Health System, Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Jiaxiang Gai
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Eduardo Trujillo-Rivera
- Department of Pediatrics, Division of Critical Care Medicine DC (AKP, MMP), Children's National Health System, Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Farhana Faruqe
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
| | - Dongkyu Kim
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - James E. Bost
- Children's National Health System (JG, FF, DK, JEB), Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
| | - Murray M. Pollack
- Department of Pediatrics, Division of Critical Care Medicine DC (AKP, MMP), Children's National Health System, Washington, DC
- George Washington University School of Medicine and Health Sciences (AKP, MMP, JG, ET-R, DK, JEB), Washington, DC
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8
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Friedman N, Kim K, Lasoff D. Accidental intravenous acetaminophen overdose in an infant without development of hepatotoxicity: a case report. Clin Toxicol (Phila) 2022; 60:775-776. [PMID: 35048751 DOI: 10.1080/15563650.2022.2028804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Nathan Friedman
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, San Diego, CA, USA.,VA San Diego Healthcare System, San Diego, CA, USA
| | - Kyu Kim
- Department of Pediatrics, Rady Children's Hospital, San Diego, CA, USA
| | - Daniel Lasoff
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, San Diego, CA, USA
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9
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Chow TYA, Chan CK, Ng SH, Tse ML. Hong Kong Poison Information Centre: Annual report 2019. HONG KONG J EMERG ME 2021. [DOI: 10.1177/10249079211038841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The Hong Kong Poison Information Centre (HKPIC) provides consultation service to health care professionals and collect epidemiological data on poisoning in Hong Kong since 2005. Objective: To report and analyse the data of Hong Kong Poison Information Centre on poisoning in 2019. Methods: This was a retrospective review of all poisoning cases recorded in the Poison Information and Clinical Management System of Hong Kong Poison Information Centre in 2019. Results: A total of 4016 poisoned cases were analysed, which involved 1698 men (42.3%), 2312 women (57.6%) and 6 sex-unspecified patients (0.1%). Majority of cases (77.3%) were between 13 and 69 years of age, and 10.5% were teenagers 13–19 years of age. Self-harm/suicidal attempt (42.1%), unintentional exposure (18.1%) and abusive substance use (11.1%) were common reasons of poisoning. Excluding ethanol, which was the common co-ingestant, the five most common types of poison were benzodiazepines, paracetamol, household products, zopiclone and Chinese herbal medicine. While most patients were managed with supportive treatment, 16.5% and 16.8% of the consultation cases were treated with decontamination and antidotes, respectively. Majority of cases recovered uneventfully, but 1.0% died and 4.7% had a major outcome. A total of six interesting cases and two outbreaks were discussed in this report. Conclusion: This 14th annual report provided updated epidemiological information on the pattern of poisoning in Hong Kong and highlighted a number of important changes compared with our previous reports.
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Affiliation(s)
- Tin Yat Anthony Chow
- Hong Kong Poison Information Centre, K3A, United Christian Hospital, Kwun Tong, China
| | - Chi Keung Chan
- Hong Kong Poison Information Centre, K3A, United Christian Hospital, Kwun Tong, China
| | - Sze Hong Ng
- Hong Kong Poison Information Centre, K3A, United Christian Hospital, Kwun Tong, China
| | - Man Li Tse
- Hong Kong Poison Information Centre, K3A, United Christian Hospital, Kwun Tong, China
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10
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Shahmirzadi G, Nooripour S, Ziari A, Danaei N. Comparison of Gastrointestinal Complications of Paracetamol and Ibuprofen in the Management of Infants with Patent Ductus Arteriosus: A Randomized Clinical Trial Study. Int J Prev Med 2021; 12:48. [PMID: 34211679 PMCID: PMC8223912 DOI: 10.4103/ijpvm.ijpvm_387_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 12/09/2019] [Indexed: 11/28/2022] Open
Abstract
Background: Patent ductus arteriosus (PDA) is one of the more common congenital heart defects in preterm neonates. The closure of PDA can be done with ibuprofen; however, this drug is associated with many contraindications and potential side-effects. In the past years, paracetamol has been proposed for the treatment of PDA. This study was designed to evaluate the efficacy and gastrointestinal complications of paracetamol and ibuprofen for the pharmacological closure of PDA in preterm infants. Methods: In a clinical trial study, 40 preterm infants with echocardiographically confirmed PDA were randomly assigned to receive either paracetamol (n = 23; 15 mg/kg every 6 h for 2 days) or ibuprofen (n = 17; initial dose of 10 mg/kg, followed by 5 mg/kg every 12 h for 2 days). The neonates matched for gestational age and weight. We used t-test for parametric, Chi-square for categorial, and Wilcoxson for nonparametric variables. Significant level was considered less than 0.05. Results: Platelet count, BUN and creatinine levels, and closure of PDA had not significant difference between two groups (P > 0.05). Incidence and severity of GI bleeding, feeding intolerance, and NEC were significantly more in infants who received paracetamol than ibuprofen (P < 0.05). Conclusions: There were no differences in the rate of PDA closure between the two drugs, but with respect to complications, rate and severity of GI bleeding, feeding intolerance, and NEC were significantly more in infants who received paracetamol than ibuprofen. Therefore, paracetamol could not be used as a proper alternative agent for ibuprofen in the treatment of PDA in preterm infants.
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Affiliation(s)
- Gohar Shahmirzadi
- Department of Pediatric, Semnan University of Medical Science, Semnan, Iran.,Students Research Committee, Semnan University of Medical Science, Semnan, Iran
| | | | - Abbas Ziari
- Social Determinants of Health Research Center, Semnan University of Medical Science, Semnan, Iran
| | - Navid Danaei
- Department of Pediatric, Semnan University of Medical Science, Semnan, Iran
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11
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Implementation of pharmacist-managed early switch from intravenous to oral therapy using electronic identification at a tertiary academic hospital. Saudi Pharm J 2021; 29:324-336. [PMID: 33994827 PMCID: PMC8093584 DOI: 10.1016/j.jsps.2021.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/06/2021] [Indexed: 11/20/2022] Open
Abstract
Overutilization of intravenous (IV) medications can result in drug shortages, which is one of the major health care crisis, in addition to increasing costs, length of hospital stays (LOS) and the associated complications. We hypothesized that IV therapy was overused at our hospital where oral (PO) was applicable, and that the implementation of IV-PO protocol could result in a cost-effective practice. Hence, we aimed at assessing impact and outcomes of implementing such a protocol. A single center, prospective quasi-interventional study conducted at tertiary academic hospital. A protocol was implemented targeting 17 medications, with educational sessions to medical staff during a 5-month phase. IV orders of 48 h or more, among adult patients at medical or surgical wards with no contraindication to PO route were eligible. Once eligible, pharmacists send interventions using hospital's computerized order entry system, and physicians' responses were monitored on daily basis. Efficacy was estimated by percentage of switch recommendations that resulted in effective switch to PO medication. Cost-minimization analysis was used for course cost between the control phase and intervention phase. Length of hospital stay (LOS), readmissions within 90 days and in-hospital mortality were analyzed as secondary outcomes. During intervention phase, 781 patients had at least one IV order switched to PO. Gastric acid-reducing agents (GARAs) accounted for the most IV prescriptions (50.4%), followed by antibiotics (39.6%). Pharmacists carried out 2677 interventions to which switch recommendations were issued in 1185 (44.3%). Primary switch recommendations (N = 677) led to effective switch in 60.7% cases. These included per protocol switch (8.9%), switch to another PO (2.5%), spontaneous switch by physician (17.6%) and IV discontinuation (31.8%). The overall efficacy was estimated as 62.8%. The intervention was associated with reduced IV consumption from 4,574-18,597 vials in control phase to 3,654-15,546 vials in intervention phase, which resulted in overall cost saving of 50,960.8 SAR ($13,589.5), with an average monthly cost saving of 10,192.2 SAR ($2,717.9). Pharmacist-managed early switch from IV-PO therapy, with physicians' education, showed significant reduction in IV medication use in our hospital. By reducing unnecessary IV use, this strategy enabled considerable cost savings, besides the potential advantages of convenience and safety.
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12
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Ochroch J, Usman A, Kiefer J, Pulton D, Shah R, Grosh T, Patel S, Vernick W, Gutsche JT, Raiten J. Reducing Opioid Use in Patients Undergoing Cardiac Surgery - Preoperative, Intraoperative, and Critical Care Strategies. J Cardiothorac Vasc Anesth 2020; 35:2155-2165. [PMID: 33069556 DOI: 10.1053/j.jvca.2020.09.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/01/2020] [Accepted: 09/09/2020] [Indexed: 02/08/2023]
Abstract
Patients undergoing cardiothoracic surgery are exposed to opioids in the operating room and intensive care unit and after hospital discharge. Opportunities exist to reduce perioperative opioid use at all stages of care and include alternative oral and intravenous medications, novel intraoperative regional anesthetic techniques, and postoperative opioid-sparing sedative and analgesic strategies. In this review, currently used and investigational strategies to reduce the opioid burden for cardiothoracic surgical patients are explored.
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Affiliation(s)
- Jason Ochroch
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Asad Usman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse Kiefer
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Danielle Pulton
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ro Shah
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Taras Grosh
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William Vernick
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse Raiten
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Efficacy and Safety of Chinese Herbs for the Prevention of the Risk of Renal Damage in Henoch-Schonlein Purpura in Children: Meta-Analysis of Randomized Controlled Trials and GRADE Evaluation. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:4089184. [PMID: 31118958 PMCID: PMC6500638 DOI: 10.1155/2019/4089184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/12/2019] [Accepted: 02/25/2019] [Indexed: 11/24/2022]
Abstract
Objective. To evaluate the efficacy and safety of traditional Chinese medicine in preventing kidney damage caused by Henoch-Schonlein Purpura (HSP) in Children by meta-analysis. Methods. We systematically searched the main Chinese and English electronic databases and collected randomized controlled trials of Chinese herbs in children with HSP until July 2018. Then we used the bias risk assessment tool in Cochrane Handbook 5. 1. 0 to complete the risk assessment of the included studies. We utilized STATA12.0 and RevMan 5.3 for meta-analysis and GRADE pro. for quality evaluation of evidence. Result. (1) Meta-analysis: data from 39 studies, representing 3643 individuals, were included in the analysis. Thirty-seven studies were treated with traditional Chinese medicine for clearing away heat and cooling blood, which were combined. On this basis, subgroup analysis was conducted according to the bias risk of the original study. It showed that Chinese herbs can significantly improve the treatment effect (OR: 4.31, 95% CI [3.34, 5.57], P < 0.01) and reduce the risk of renal damage (RR: 0.36; 95% CI [0.21, 0.61], P < 0.01) and the risk of recurrence (RR: 0.43, 95% CI [0.34, 0.54], P<0.01). (2) Side effect: a total of 7 studies described adverse reactions, and 12 of 319 patients in therapy group had adverse events and 20 of 263 patients in control group. (3) Publication bias: the bias risk Egger's test for the incidence of kidney injury was P=0.572, the relapse rate Egger's test was P=0.175, the efficiency was combined with the low-risk original study, and the bias risk Egger's test was P=0.175. There was not any significant publication bias based on the funnel plot and Egger's test. (4) GRADE evaluation: GRADE evaluation showed that the quality of evidence in the risk of renal damage and recurrence rate was moderate. Conclusion. Chinese medicine treatment can prevent the occurrence of renal damage in children with HSP and can reduce the recurrence rate, the incidence of adverse reactions, and the effect in terms of efficiency. However, the quality of the included studies in the meta-analysis and the quality of the evidence of outcomes were not high; the clinical use of the evidence needs to be cautious.
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Abstract
Paracetamol is a common antipyretic often used to treat children with fever and pain. With the increasing administration of intravenous (IV) paracetamol, there will be the associated risk of medication dosing errors. We report a case of IV paracetamol overdose in a child with fever during hospital admission. A IV paracetamol dosing error occurred, with delayed recognition resulting in transient hepatotoxicity, with a peak alanine transaminase of 1946 IU/L and aspartate transaminase of 1633 IU/L.
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Vincent WR, Huiras P, Empfield J, Horbowicz KJ, Lewis K, McAneny D, Twitchell D. Controlling postoperative use of i.v. acetaminophen at an academic medical center. Am J Health Syst Pharm 2018; 75:548-555. [PMID: 29467148 DOI: 10.2146/ajhp170054] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Results of an interprofessional formulary initiative to decrease postoperative prescribing of i.v. acetaminophen are reported. SUMMARY After a medical center added i.v. acetaminophen to its formulary, increased prescribing of the i.v. formulation and a 3-fold price increase resulted in monthly spending of more than $40,000, prompting an organizationwide effort to curtail that cost while maintaining effective pain management. The surgery, anesthesia, and pharmacy departments applied the Institute for Healthcare Improvement's Model for Improvement to implement (1) pharmacist-led enforcement of prescribing restrictions, (2) retrospective evaluation of i.v. acetaminophen's impact on rates of opioid-related adverse effects, (3) restriction of prescribing of the drug to 1 postoperative dose on select patient care services, and (4) guideline-driven pain management according to an enhanced recovery after surgery (ERAS) protocol. Monitored metrics included the monthly i.v. acetaminophen prescribing rate, the proportion of i.v. acetaminophen orders requiring pharmacist intervention to enforce prescribing restrictions, and prescribing rates for select adjunctive analgesics. Within a year of project implementation, the mean monthly i.v. acetaminophen prescribing rate decreased by 83% from baseline to about 6 doses per 100 patient-days, with a decline in the monthly drug cost to about $4,000. Documented pharmacist interventions increased 2.7-fold, and use of oral acetaminophen, ketorolac, and gabapentin in ERAS areas increased by 18% overall. CONCLUSION An interprofessional initiative at a large medical center reduced postoperative use of i.v. acetaminophen by more than 80% and yielded over $400,000 in annual cost savings.
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Affiliation(s)
| | - Paul Huiras
- Department of Pharmacy, St. Cloud Hospital, St. Cloud, MN
| | - Jennifer Empfield
- Department of Pharmacy, Jefferson University Hospitals, Philadelphia, PA
| | | | - Keith Lewis
- Department of Anesthesiology, Boston Medical Center, Boston, MA
| | - David McAneny
- Department of Surgery, Boston Medical Center, Boston, MA
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Welsh J, Welsh T. The Safe and Successful Management of Acute Pain in the Infant and Young Child. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2018. [DOI: 10.1007/s40138-018-0153-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Caparrotta TM, Antoine DJ, Dear JW. Are some people at increased risk of paracetamol-induced liver injury? A critical review of the literature. Eur J Clin Pharmacol 2017; 74:147-160. [PMID: 29067481 PMCID: PMC5765191 DOI: 10.1007/s00228-017-2356-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 10/15/2017] [Indexed: 12/18/2022]
Abstract
Purpose Paracetamol is one of the world’s most commonly used drugs. In overdose, it is well established to be hepatotoxic. The aim of this review was to identify factors that have been, or actually are, associated with the development of liver injury after paracetamol exposure in humans. Method Google Scholar and PubMed were searched on various dates between December 2016 and March 2017. Papers identified had their references analysed for further studies that might be relevant. Results At the time of writing, there was little good quality clinical evidence—from studies of paracetamol overdose or therapeutic use—to suggest that any groups of people are relatively protected from, or are at greater risk of, liver injury. The factors that were historically used to indicate higher risk in the UK have no good quality clinical evidence to support their re-introduction into clinical practice. The safe (and still effective) oral dose of paracetamol in patients weighing less than 50 kg has not been established. Conclusion There is no patient group that is unequivocally at elevated risk of paracetamol-induced liver toxicity. We propose two clinical scenarios that warrant further research. Firstly, there is a need to establish whether the dose of paracetamol should be reduced in patients with low body weight. Secondly, if or when genomic information regarding individual patients becomes readily available to inform prescribing, we propose the contribution of the genome to paracetamol toxicity should be re-investigated with robustly designed studies. Such studies could enhance the safe use of one of the most frequently taken drugs. Electronic supplementary material The online version of this article (10.1007/s00228-017-2356-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas M Caparrotta
- Speciality Registrar Clinical Pharmacology and Therapeutics, NHS Lothian, Edinburgh, UK
| | - Daniel J Antoine
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - James W Dear
- University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
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Paracetamol in Patent Ductus Arteriosus Treatment: Efficacious and Safe? BIOMED RESEARCH INTERNATIONAL 2017; 2017:1438038. [PMID: 28828381 PMCID: PMC5554551 DOI: 10.1155/2017/1438038] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/22/2017] [Accepted: 06/11/2017] [Indexed: 12/19/2022]
Abstract
In preterm infants, failure or delay in spontaneous closure of Ductus Arteriosus (DA), resulting in the condition of Patent Ductus Arteriosus (PDA), represents a significant issue. A prolonged situation of PDA can be associated with several short- and long-term complications. Despite years of researches and clinical experience on PDA management, unresolved questions about the treatment and heterogeneity of clinical practices in different centers still remain, in particular regarding timing and modality of intervention. Nowadays, the most reasonable strategy seems to be reserving the treatment only to hemodynamically significant PDA. The first-line therapy is medical, and ibuprofen, related to several side effects especially in terms of nephrotoxicity, is the drug of choice. Administration of oral or intravenous paracetamol (acetaminophen) recently gained attention, appearing effective as traditional nonsteroidal anti-inflammatory drugs (NSAIDs) in PDA closure, with lower toxicity. The results of the studies analyzed in this review mostly support paracetamol efficacy in ductal closure, with inconstant low and transient elevation of liver enzymes as reported side effect. However, more studies are needed to confirm if this therapy shows a real safety profile and to evaluate its long-term outcomes, before considering paracetamol as first-choice drug in PDA treatment.
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Oncel MY, Erdeve O. Oral medications regarding their safety and efficacy in the management of patent ductus arteriosus. World J Clin Pediatr 2016; 5:75-81. [PMID: 26862505 PMCID: PMC4737696 DOI: 10.5409/wjcp.v5.i1.75] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 11/22/2015] [Accepted: 01/07/2016] [Indexed: 02/05/2023] Open
Abstract
Patent ductus arteriosus (PDA) is a common clinical condition in preterm infants which is inversely related to birth weight and gestational age. Cyclooxygenase inhibitors such as indomethacin and ibuprofen which block the prostaglandin conversion from arachidonic acid are the most commonly used drugs for ductal closure. This review focuses on the safety and efficacy oral medications in the management of PDA in preterm infants. Ibuprofen seems to be the first choice due to its higher safety profile, as it is associated with fewer gastrointestinal and renal side effects when compared to indomethacin. PDA closure rates are better with oral than with intravenous ibuprofen probably due to the pharmacokinetic of the drug. However, these medications were reported to be associated with several adverse including transient renal failure, gastrointestinal bleeding and perforation, hyperbilirubinemia and platelet dysfunction. Paracetamol seems be an alternative to PDA therapy with lower adverse events and side effects.
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Eftekharian H, Tabrizi R, Kazemi H, Nili M. Evaluation of a Single Dose Intravenous Paracetamol for Pain Relief After Maxillofacial Surgery: A Randomized Clinical Trial Study. J Maxillofac Oral Surg 2015. [PMID: 26225014 DOI: 10.1007/s12663-013-0557-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate, using a single dose of intravenous paracetamol, pain relief after maxillofacial surgery. MATERIALS AND METHODS This is a controlled, randomized, uni- blind, clinical trial study to evaluate using a single dose of IV paracetamol for pain relief after maxillofacial surgery. The subjects were randomly divided into two groups with 40 subjects in each: group I received paracetamol (Apotel)* as a single dose and group II received placebo. Subjects were randomly allocated according to randomization lists. Paracetamol was used as a single dose (20 mg/kg in 100 cc of normal saline which was infused for 10 min after surgery in recovery room just before discharging). We used a visual analogue scale to investigate pain relief at various times. RESULTS Analysis of the data, did not show any significant difference for age, sex and weight between the treatment group and the control group. Pain decreased 6 h after paracetamol infusion; then it increased mildly. In the control group, pain severity increased after operation, then it decreased mildly. Results showed a correlation between duration of surgery and pain severity in both the groups. CONCLUSION Paracetamol is effective on pain relief after maxillofacial surgeries. Operation time may be an important factor for induction of pain after the surgeries.
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Affiliation(s)
- Hamidreza Eftekharian
- Department of Maxillofacial Surgery, Shiraz University of Medical Science, Shiraz, Iran
| | - Reza Tabrizi
- Department of Maxillofacial Surgery, Shiraz University of Medical Science, Shiraz, Iran ; Chamran Hospital, CMF Ward, Chamran Avenue, Shiraz, Fars Iran
| | - Hamidreza Kazemi
- Department of Maxillofacial Surgery, Shiraz University of Medical Science, Shiraz, Iran
| | - Mahsa Nili
- Shiraz University of Medical Science, Shiraz, Iran
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23
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Abstract
Acetaminophen is a commonly used pediatric medication that has recently been approved for intravenous use in the United States. The purpose of this article was to review the pharmacodynamics, indications, contraindications, and precautions for the use of intravenous acetaminophen in pediatrics.
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25
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Abstract
The past 2-3 decades have seen dramatic changes in the approach to pain management in the neonate. These practices started with refuting previously held misconceptions regarding nociception in preterm infants. Although neonates were initially thought to have limited response to painful stimuli, it was demonstrated that the developmental immaturity of the central nervous system makes the neonate more likely to feel pain. It was further demonstrated that untreated pain can have long-lasting physiologic and neurodevelopmental consequences. These concerns have resulted in a significant emphasis on improving and optimizing the techniques of analgesia for neonates and infants. The following article will review techniques for pain assessment, prevention, and treatment in this population with a specific focus on acute pain related to medical and surgical conditions.
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Affiliation(s)
- Tarun Bhalla
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, U.S ; Department of Anesthesiology, Ohio State University, Columbus, Ohio, U.S
| | - Ed Shepherd
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, U.S ; Department of Pediatrics, Ohio State University, Columbus, Ohio, U.S
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, U.S ; Department of Anesthesiology, Ohio State University, Columbus, Ohio, U.S ; Department of Pediatrics, Ohio State University, Columbus, Ohio, U.S
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Dokko D. Best practice for fever management with intravenous acetaminophen in pediatric oncology. J Pediatr Oncol Nurs 2014; 32:120-5. [PMID: 25037174 DOI: 10.1177/1043454214543018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Intravenous (IV) acetaminophen was introduced in the United States in 2011 for use as an analgesic and antipyretic agent. While no studies have looked at its utilization specifically in the pediatric oncology population, existing literature suggests IV acetaminophen is safe and effective to use in both children and adults. This article aims to review and apply current data in evaluating whether or not children with cancer can safely benefit from its use. This article provides clinical indications, safety and efficacy profiles, and nursing implications along with recommendations for future study regarding the use of IV acetaminophen in this population.
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Nour C, Ratsiu J, Singh N, Mason L, Ray A, Martin M, Hassanian M, Uhler J, Applegate RL. Analgesic effectiveness of acetaminophen for primary cleft palate repair in young children: a randomized placebo controlled trial. Paediatr Anaesth 2014; 24:574-81. [PMID: 24697925 DOI: 10.1111/pan.12393] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Clefting of the lip, palate, or both is a common congenital abnormality. Inadequate treatment for pain in children may result from concerns over opioid-related adverse effects. Providing adequate pain control with minimal adverse effects remains challenging in children. OBJECTIVES To assess opioid-sparing effects of oral or intravenous acetaminophen following primary cleft palate repair in children. METHODS Prospective randomized controlled trial in 45 healthy children, ages 5 months to 5 years, using standardized general anesthesia and lidocaine infiltration of the operative field. Patients were allocated to groups: intravenous acetaminophen/oral placebo (intravenous), oral acetaminophen/intravenous placebo (oral), or intravenous/oral placebo (control). Groups were compared for differences in opioid administration during the 24-h study period (morphine equivalents µg·kg(-1) ; 95% confidence interval). RESULTS Intravenous acetaminophen decreased opioid requirement after surgery (P = 0.003). Patients in the intravenous group received less opioid (272.9; 202.9-342.8 µg·kg(-1) ) than control patients (454.2; 384.3-524.2 µg·kg(-1) ; P < 0.002). Opioid requirement in oral patients (376.5; 304.1-448.9 µg·kg(-1) ) was intermediate and not significantly different from either intravenous (P = 0.11) or control (P = 0.27). During the ward phase of care, intravenous had better analgesia than control (P = 0.002), and both intravenous and oral group patients received less opioid than control (P = 0.01). CONCLUSION Intravenous acetaminophen given to young children undergoing primary cleft palate repair was associated with opioid-sparing effects compared to placebo. The fewer morphine doses during ward stay in both intravenous and oral may be important clinically in some settings.
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Affiliation(s)
- Chelan Nour
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, CA, USA
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Jitpakdee T, Mandee S. Strategies for preventing side effects of systemic opioid in postoperative pediatric patients. Paediatr Anaesth 2014; 24:561-8. [PMID: 24809837 DOI: 10.1111/pan.12420] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Opioid is the gold standard for treating moderate-to-severe pain in pediatric patients. However, its undesirable side effects lead to unsatisfied postoperative pain management outcome (Pediatr Anesth, 17, 2007, 756). The most commonly reported opioid-related side effects are vomiting (40%), pruritus (20-60%) (Anesthesiology, 77, 1992, 162; Drugs, 67, 2007, 2323), and constipation (15-90%) (Int J Clin Pract, 61, 2007, 1181). The potential life-threatening adverse event, respiratory depression, is less common (0.0013%) (Pediatr Anesth, 20, 2010, 119). The aim of this review was to evaluate prevention strategies that have been shown to decrease opioid side effects in pediatric patients during the postoperative period. METHODS Literature searches were conducted from 1984 to February 2013. Meta-analysis, systematic review, and randomized, placebo-controlled studies were obtained from PubMed and the Cochrane Library. The medical subject heading (MeSH) terms were opioid analgesics, adverse effects, pediatrics, children, side effects, and postoperative pain. RESULTS AND CONCLUSION Data from 62 studies were reviewed. The strategies that could effectively prevent and reduce opioid side effects in pediatric patients during the postoperative period included minimizing the amount of opioid consumption by a multimodal approach, opioid titration, using local anesthetic techniques and providing the specific prophylaxis for each side effect.
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Affiliation(s)
- Thanaporn Jitpakdee
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkoknoi, Bangkok, Thailand
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Fusco NM, Parbuoni K, Morgan JA. Drug utilization, dosing, and costs after implementation of intravenous acetaminophen guidelines for pediatric patients. J Pediatr Pharmacol Ther 2014; 19:35-41. [PMID: 24782690 DOI: 10.5863/1551-6776-19.1.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objectives of this evaluation of medication use were to characterize the use of intravenous acetaminophen at our institution and to determine if acetaminophen was prescribed at age-appropriate dosages per institutional guidelines, as well as to evaluate compliance with restrictions for use. Total acquisition costs associated with intravenous acetaminophen usage is described as well. METHODS This retrospective study evaluated the use of acetaminophen in pediatric patients younger than 18 years of age, admitted to a tertiary care hospital, who received at least 1 dose of intravenous acet-aminophen between August 1, 2011, and January 31, 2012. RESULTS A total of 52 doses of intravenous acetaminophen were administered to 31 patients during the 6-month study period. Most patients were admitted to the otorhinolaryngology service (55%), and the majority of doses were administered either in the operating room (46%) or in the intensive care unit (46%). Nineteen doses (37%) of intravenous acetaminophen were administered to patients who did not meet institutional guidelines' eligibility criteria. Three patients received single doses of intravenous acetaminophen that were greater than the dose recommended for their age. One patient during the study period received more than the recommended 24-hour maximum cumulative dose for acetaminophen. Total acquisition cost of intravenous acetaminophen therapy over the 6-month study period was $530.40. CONCLUSIONS Intravenous acetaminophen was used most frequently among pediatric patients admitted to the otorhinolaryngology service during the perioperative period. Nineteen doses (37%) were administered to patients who did not meet the institutional guidelines' eligibility criteria. Our data support reinforcing the availability of institutional guidelines to promote cost-effective use of intravenous acetaminophen while minimizing the prescription of inappropriate doses.
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Affiliation(s)
- Nicholas M Fusco
- Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, New York
| | - Kristine Parbuoni
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, California
| | - Jill A Morgan
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy Baltimore, Maryland
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Abstract
Pediatric patients often undergo anesthesia for ambulatory procedures. This article discusses several common preoperative dilemmas, including whether to postpone anesthesia when a child has an upper respiratory infection, whether to test young women for pregnancy, which children require overnight admission for apnea monitoring, and the effectiveness of nonpharmacological techniques for reducing anxiety. Medication issues covered include the risks of anesthetic agents in children with undiagnosed weakness, the use of remifentanil for tracheal intubation, and perioperative dosing of rectal acetaminophen. The relative merits of caudal and dorsal penile nerve block for pain after circumcision are also discussed.
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Affiliation(s)
- David A August
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB-444, Boston, MA 02114, USA.
| | - Lucinda L Everett
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB-415, Boston, MA 02114, USA
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Marzuillo P, Guarino S, Barbi E. Paracetamol: a focus for the general pediatrician. Eur J Pediatr 2014; 173:415-25. [PMID: 24374658 DOI: 10.1007/s00431-013-2239-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 12/05/2013] [Indexed: 02/02/2023]
Abstract
UNLABELLED Paracetamol (acetaminophen) is one of the most popular and widely used drugs for the treatment of pain and fever in children. This drug has multiple mechanisms of action, but its pharmacodynamic is still not well known. The central nervous system is the main site of action and it mirrors the paracetamol effect compartment. The recommended dosages and routes of administration should be different whether paracetamol is used for the treatment of pain or fever. For example, the rectal route, while being efficacious for the treatment of fever, should be avoided in pain management. Paracetamol is a safe drug, but some clinical conditions and concomitant drugs, which are frequent in clinical practice, may increase the risk of paracetamol toxicity. Therefore, it is important to optimize its administration to avoid overdoses and maximize its effect. The principal mediator of the paracetamol toxicity is the N-acetyl-p-benzo-quinone imine (NAPQI), a toxic product of the paracetamol metabolism, which could bind cysteine groups on proteins forming paracetamol-protein adduct in the liver. CONCLUSION Although frequently prescribed, the concept of "effect compartment concentration" and the possible co-factors that could cause toxicity at recommended doses are not familiar to all pediatricians and general practitioners. We reviewed the literature concerning paracetamol mechanisms of action, we highlighted some relevant pharmacodynamic concepts for clinical practice, and we summarized the possible risk factors for toxicity at therapeutic dosages.
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Affiliation(s)
- Pierluigi Marzuillo
- Department of Women and Children and General and Specialized Surgery, Seconda Università degli Studi di Napoli, Via L. De Crecchio 2, 80138, Naples, Italy,
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Marks AD, Keefer P, Saul D. Use of Intravenous Acetaminophen (Paracetamol) in a Pediatric Patient at the End of Life: Case Report. J Palliat Med 2013; 16:1641-3. [DOI: 10.1089/jpm.2012.0117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Adam D. Marks
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Division of Geriatrics and Palliative Care, University of Michigan, Ann Arbor, Michigan
| | - Patricia Keefer
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan
| | - D'Anna Saul
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan
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Abstract
Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).
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Intravenous acetaminophen: a review of pharmacoeconomic science for perioperative use. Am J Ther 2013; 20:189-99. [PMID: 23466620 DOI: 10.1097/mjt.0b013e31828900cb] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hospitals are subject to more economic pressures than ever before. On the one hand, cost containment or cost reduction is paramount, particularly in relation to costly branded pharmaceuticals. On the other hand, quality measures and value-based reimbursement penalizes poor patient care. Multimodal analgesia sits squarely in this quandary, since its very nature requires use of multiple drugs with their associated costs, though this approach has the potential to improve quality of care. We undertook a comprehensive review of the pharmacoeconomics of IV acetaminophen, a new drug useful as part of a multimodal analgesic approach. While this new branded drug adds to direct drug costs, there is clear potential for IV acetaminophen to reduce the incidence of opioid-related adverse events and, in so doing, result in net hospital savings. This review describes many clinical studies showing significant improvements in postoperative nausea and vomiting, excessive sedation and pruritus. In addition, we describe studies demonstrating faster recovery times in the post-anesthesia care unit, intensive care unit and total hospital length of stay. Lastly, we summarize many studies demonstrating the robust effect of IV acetaminophen on patient satisfaction. A holistic view of total hospital performance should be adopted when reviewing drugs rather than a silo mentality within the pharmacy. While IV acetaminophen adds to drug costs, the body of evidence indicates this drug has the potential to improve outcomes and hospital efficiency.
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O'Neal JB. The utility of intravenous acetaminophen in the perioperative period. Front Public Health 2013; 1:25. [PMID: 24350194 PMCID: PMC3854978 DOI: 10.3389/fpubh.2013.00025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 07/18/2013] [Indexed: 11/13/2022] Open
Abstract
Intravenous acetaminophen (IVA) has rapid and effective analgesic properties. Recent studies have shown several benefits of using IVA perioperatively. However, due to its relatively high cost and limited clinical data concerning its efficacy compared with other agents, physicians are hesitant to use IVA in the perioperative period. This brief review examines the utility of this medication in the perioperative period and highlights future areas of clinical and epidemiological research regarding its use.
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Affiliation(s)
- Jason B O'Neal
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
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Schwartz SB, Rauch D. Intravenous acetaminophen: an alternative to opioids for pain management? Hosp Pediatr 2013; 3:294-296. [PMID: 24313101 DOI: 10.1542/hpeds.2013-0014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Sarah B Schwartz
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.
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XXXIII International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 28–31 May 2013, Copenhagen, Denmark. Clin Toxicol (Phila) 2013. [DOI: 10.3109/15563650.2013.785188] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Allegaert K. Clinical pharmacology of intravenous paracetamol in perinatal medicine. World J Anesthesiol 2013; 2:1-7. [DOI: 10.5313/wja.v2.i1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Accepted: 04/16/2013] [Indexed: 02/06/2023] Open
Abstract
Clinical pharmacology aims to predict drug-related effects based on compound and population specific pharmacokinetics (PK, concentration-time), and pharmacodynamics (PD, concentration-effect). Consequently, dosing needs to be based on the physiological characteristics of the individual patient. Pregnancy and early infancy hereby warrant focused assessment. The specific characteristics of both subpopulations will be illustrated based on observations on intravenous (iv) paracetamol PK and PD collected in these specific populations. At delivery, there is a significant higher paracetamol clearance (+ 45%, L/h) when compared to non-pregnant observations. This higher clearance is in part explained by a proportional increase in oxidative metabolite production, but mainly an increase in glucuronidation. When focusing on PD, an association between maternal paracetamol exposure and atopy in infancy and fetal gastroshizis has been reported. In early infancy, paracetamol clearance is significantly lower and mainly depends on size (weight 0.75), while also the distribution volume is higher (L/kg). Reports on hepatic tolerance, haemodynamic stability and impact of body temperature have been published while the concentration effect profile for analgesia seems to be similar between neonates and children. Similar to maternal exposure, there are reports on the association with atopy. Studies on the use of paracetamol to close the patent ductus arteriosus are ongoing. At least, these observations provide evidence on the need to study commonly administered anesthetics in such specific subpopulations with specific focus on both population specific PK and PD to further improve patient tailored pharmacotherapy.
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Allegaert K, Tibboel D, van den Anker J. Pharmacological treatment of neonatal pain: in search of a new equipoise. Semin Fetal Neonatal Med 2013; 18:42-7. [PMID: 23107602 PMCID: PMC4709244 DOI: 10.1016/j.siny.2012.10.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Inadequate management of pain in early human life contributes to impaired neurodevelopmental outcome and alters pain thresholds, pain or stress-related behavior and physiological responses. However, there are also emerging animal experimental data on the impact of exposure to analgo-sedatives on the incidence and extent of neuro-apoptosis. Since this association has also been suggested in humans, the pharmacological treatment of neonatal pain is in search of a new equipoise since these 'conflicting' observations are the main drivers to further reconsider our current treatment regimens. This review focuses on new data concerning clinical pharmacology of morphine, followed by data on more recently introduced opioids like remifentanil and tramadol, locoregional anesthesia and minimally invasive techniques in neonates, and finally with data on intravenous paracetamol. Since the available data are still incomplete, priorities for both clinical management and future research will be proposed.
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Affiliation(s)
- Karel Allegaert
- Neonatal Intensive Care Unit, University Hospital, Herestraat 49, 3000 Leuven, Belgium.
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Abstract
Paracetamol (acetaminophen) overdose remains the leading cause of death or transplantation due to acute liver failure in many parts of the world. Acetylcysteine has long been recognized as an effective antidote, via oral or intravenous administration, minimizing the risk and severity of acute liver injury if administered sufficiently early after a paracetamol overdose. Despite this, its mechanisms of action remain obscure, and there is uncertainty regarding the optimal dose and duration of treatment. The intravenous infusion protocol was originally developed as a three-step loading regimen; it causes very high early peak plasma concentrations of acetylcysteine whereas the later maintenance infusion is associated with much lower concentrations. This pharmacokinetic profile is associated with two particular concerns: a high rate of occurrence of adverse effects that occur after the initial loading infusion, and the possibility that the maintenance phase of treatment might deliver too low a dose of acetylcysteine for optimum protection against liver injury. Recently described novel administration regimens offer different rates of intravenous acetylcysteine administration in both the loading and maintenance phases. These alternative regimens appear to be well tolerated in small patient groups, but too few clinical data are available to evaluate their comparative efficacy in preventing paracetamol-induced liver injury.
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Affiliation(s)
- W Stephen Waring
- Acute Medical Unit, York Teaching Hospital NHS Foundation Trust, Wigginton Road, York YO31 8HE, UK
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