Approaches toward repeated supratherapeutic doses of paracetamol in children: a survey of medical directors of poison centres in North America and Europe

Life-threatening hyponatremia due to intravenous n-acetylcysteine treatment in an infant: a case report

Introduction

N-acetylcysteine has proven to be effective in paracetamol intoxications, but there is no consensus regarding its way of administration. Here, we report a case to highlight the importance of careful management of intravenous n-acetylcysteine.

Case presentation

A two-month old infant was seen in our paediatric emergency department due to paracetamol poisoning after repeated supratherapeutic doses. She was treated with intravenous n-acetylcysteine diluted with dextrose 5%, according to the 20-hour standard protocol. Eight hours later she developed two tonic-clonic seizures and was subsequently intubated. By that time, she had received almost 1 liter of 5% dextrose, and serum sodium was 114 mg/dL. A rapid correction was done with hypertonic saline and the child experienced a good outcome, without any sequelae.

Conclusion

Intravenous n-acetylcysteine administration must be done carefully. Amount of liquid administrated and sodium monitoring should be kept in mind, with special care in small children.

Repeated supratherapeutic doses of paracetamol in children--a literature review and suggested clinical approach

The safety of paracetamol when given in the recommended dosage is well documented. However, in recent years there have been many reports of liver failure associated with repeated exposure to supratherapeutic doses of paracetamol. This paper reviews the literature on chronic supratherapeutic paracetamol exposure in children and the different dosing guidelines. Based on which, we suggest the following approach: liver injury secondary to repeated dosing of paracetamol should be considered when a child has received more than 75 mg/kg/d for at least 2 d, or if risk factors for paracetamol toxicity have been identified. Liver transaminases, coagulation factors, and paracetamol serum concentrations should be measured in these children and in symptomatic children with vomiting, right upper quadrant abdominal pain, and jaundice who have taken paracetamol. Treatment with N-acetyl cysteine should be started regardless of paracetamol concentrations if transaminases or INR are elevated.

CONCLUSION

Liver injury secondary to repeated dosing of paracetamol is rare but may result in severe morbidity and mortality. The cumulative dose of paracetamol should not exceed 75 mg/kg/d. Children treated with higher doses for more than 2 d should be evaluated for possible liver injury and treated with N-acetyl cysteine if evidence of liver injury is found.

Postoperative analgesia in infants and children

PURPOSE OF REVIEW

Although postoperative analgesia in infants and children should be an integral part of the perioperative management, undertreatment of pain is not rare in clinical practice and may influence outcome and long term behaviour. Therefore, this review summarizes results of recent papers and discusses actual trends and future perspectives concerning postoperative pharmacologic pain therapy in infants and children.

RECENT FINDINGS

A multimodal approach using locoregional anesthesia and systemic analgesics is a widely accepted technique. New developments include new local anesthetics with a wider margin of safety and more experience with adjuvants, catheter techniques and systemic analgesics. Replacement of bupivacaine with ropivacaine may be prudent especially for prolonged epidural infusion, use in neonates, impaired hepatic metabolic function, and anesthetic techniques requiring large dosage of local anesthetic. The limited duration of analgesia after single blocks can be prolonged by use of adjuvants (clonidine, ketamine), catheter techniques or early use of systemic analgesics. Non-opioids (acetaminophen, non-steroidal anti-inflammatory drugs) are appropriate for patients with mild to moderate pain or as a component of multimodal pain therapy. Patient- and nurse-controlled analgesia are convenient ways for opioid administration in infants and children.

SUMMARY

The reviewed studies suggest that there are many reliable agents and techniques available to provide a safe and effective postoperative analgesia even in neonates and small infants.