Medication errors involving intravenous paracetamol in children: experience from enquiries to the National Poisons Information Service

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.

1456 Fatal propranolol overdoses reported to the UK National Poisons Information Service (NPIS) over 5 years 01/01/2017–31/12/2021

Aims, Objectives and Background

Propranolol is widely prescribed and between 2007 and 2017 dispensing in the UK increased by some 41%. In the same period, deaths in England and Wales following propranolol overdose increased by 205%.

Method and Design

We retrospectively reviewed cases of fatal propranolol poisoning reported to the UK NPIS, between 01/01/2017 and 31/12/2021 to understand the demographics of these exposures, the doses involved and treatments administered.

Results and Conclusion

There were 46 fatalities (aged 14–70 years) with 57% (n=26) of them being less than 40 years of age, and the majority of these being female (77%; n=20). Thirteen cases involved propranolol only and in the 33 cases of mixed overdose the mean number of co-ingestants was two, with a maximum of 13. An antidepressant was co-ingested in 21 cases. The reported dose of propranolol ingested was documented in 23/46 cases, median 3,200 mg (IQR 1,920–4,480 mg) and in three patients exceeded 7,000 mg. Cardiac arrest prior to contact with the NPIS was recorded in 41/46 cases. Fourteen (34%) occurred in hospital and twenty-three out-of-hospital (56%). Patients received: sodium bicarbonate (n=30, 65%), glucagon bolus and/or infusion (n=38, 83%), high dose insulin/dextrose (n=36, 78%), inotropes or vasopressors (n=36, 78%), intralipid (n=25, 54%) and ECMO was commenced in two cases. The dose of insulin administered was known in 15 cases (median dose 4 unit/kg/hour). Doses more than or equal to 8 unit/kg/hour were given in 7 cases (maximum 10 unit/kg/hour in three cases).

Young adults particularly females accounted for the majority of fatalities. In almost half of all cases an antidepressant was co-ingested. Clinicians should be aware of the potential for rapid deterioration and severe clinical outcomes following propranolol overdose. Rapid access to expert clinical advice is available through the National Poisons Information Service and is strongly recommended in order to optimise use of available treatments.

1455 A 10-year review of insulin-related enquiries to the UK National Poisons Information Service (NPIS)

Aims, Objectives and Background

More than 4.9 million people in the UK have diabetes, and sufferers are at increased risk of depression.1We reviewed enquiries to the NPIS about insulin overdose.

Method and Design

Retrospective analysis of enquiries between 1 November 2011 and 31 October 2021.

Results and Conclusion

We received 1195 enquiries involving insulin. Further analysis was limited to the 169 enquiries involving insulin only (90.5% via injection).

Most enquiries (88%) concerned adults ≥ 18 years. There were 34 non-diabetic and 98 diabetic patients: 32 Type 1, 10 Type 2, and 56 type undocumented. Exposures were intentional (n=114, 68%), from therapeutic error (n=28), accidental (n=16) or circumstances unknown (n=11).

Long-acting insulins were involved in 71 cases, and the highest dose was 20000 units (table 1). The lowest recorded blood glucose concentration (mmol/L) at the time of the enquiry was in the range 0–0.9 (n=7), 1.0–1.9 (n=29), 2.0–2.9 (n=25), 3.0–3.9 (n=12), >4.0 (n=14). Hypokalaemia (defined as K+<3.5 mmol/L) was noted in 26 (n=15%) enquiries. The maximum Poisoning Severity2(n=162) was graded: none (n=55), minor (n=29), moderate (n=44), and severe (n=34).

Treatments given prior to contacting the NPIS were IV glucose (n=91, 54%), IV/IM glucagon (n=26, 15%), IV octreotide (n=6, 4%) and IV corticosteroids (n=2, 1%). No patient underwent surgical excision of the injection site. Long-acting insulins accounted for 5/6 cases where octreotide was given.

Abstract 1455 Table 1

Details of dose, insulin type, nadir blood glucose concentration, and Poisoning Severity Score in 169 cases of insulin poisoning reported to the UK National Poisons Information Service in the ten years to 31st October 2021. Ø = unrecordable

Insulin type*Median dose Units (range)Lowestblood glucoseconcnmmol/L (mg/dL)Known diabeticpatientsMaximum poisoning severityModeraten% of all moderateSeveren% of all severeLong acting (N=71)600 (10–20000)Ø492352%1441%Medium acting (N=24)900 (60–4500)0.6 (11)11818%721%Short acting (N=14)75 (28–2000)1.6 (29)737%13%Ultrashort acting (N=35)180 (1.5–4800)1 (18)231023%515%Unknown (N=18)188 (45–400)Ø800%721%Canine (N=7)20 (7–1600)4.2 (76)000%00%

*Where two or more insulin types or mixtures were involved (n=55, 32.5%), the longest-acting component was counted.

Conclusions

Hypoglycaemia following insulin overdose was mostly managed satisfactorily by intravenous glucose infusion, with glucagon used occasionally. The role of octreotide and corticosteroids was unclear. Approximately 20% of cases were severe, especially following overdose of medium- and long-acting insulins; we recorded no fatalities.

References

https://www.diabetes.org.uk/professionals/position-statements-reports/statistics. Accessed February 2022.

Persson HE, Sjöberg GK, Haines JA, De Garbino JP. Poisoning severity score. Grading of acute poisoning.J Toxicol Clin Toxicol1998;36: 205–213.

Carbon monoxide exposures reported to the UK National Poisons Information Service: a 4-year study

BACKGROUND

Unintentional carbon monoxide (CO) poisoning poses a public health challenge. The UK National Poisons Information Service (NPIS) provides advice to healthcare professionals via the online database, TOXBASE®, and a 24-hour telephone line. Our aim was to analyse all CO-related enquiries to the NPIS.

METHODS

We analysed enquiries regarding unintentional CO exposure (1st July 2015-30th June 2019). Information on patient demographics, CO source and location, clinical features and poisoning severity was collected from telephone enquiries and TOXBASE accesses.

RESULTS

2970 unintentional non-fire-related CO exposures were reported. Exposures occurred commonly in the home (60%) with faulty boilers frequently implicated (27.4%). Although five fatalities were reported, 68.7% of patients experienced no or minor symptoms only (headache most frequently reported). Despite being the gold standard measurement, blood carboxyhaemoglobin concentration was only recorded in 25.6% patients, with no statistically significant correlation with severity.

CONCLUSIONS

Unintentional CO exposures in the UK commonly occur in domestic settings and although are generally of low severity, fatalities continue to occur. Carboxyhaemoglobin measurement is important to confirm exposure but further work is required to assess its validity as a prognostic indicator in CO exposure. Public health policy should continue to focus on raising awareness of the dangers of CO.

Elective alcohol detoxification - a resource and efficacy evaluation

An evaluation was performed to assess efficacy and resource utilisation of an elective inpatient alcohol detoxification service at a large inner-city teaching hospital. Abstinence rates at 3, 6 and 12 months post-detoxification were 68.1, 44.7 and 36.2%, respectively. Relapse was associated with referrals from acute hospital services, previous detoxifications, longer time between referral and admission for detoxification, presence of alcohol in the blood on the day of admission and requirement for benzodiazepines during withdrawal. The service operates within the national 18-week referral target and runs at a cost substantially lower than that of residential alcohol detoxification facilities but with similar sobriety rates. We demonstrate that elective detoxification with specialist follow-up provides an effective service both in terms of patient outcomes and resource use. Further investment in these services at both local and national level should be considered.

Hospital usage of TOXBASE in Great Britain: Temporal trends in accesses 2008 to 2015

AIM

To examine temporal trends in accesses to the UK's National Poison Information Service's TOXBASE database in Britain.

METHODS

Generalized additive models were used to examine trends in daily numbers of accesses to TOXBASE from British emergency departments between January 2008 and December 2015. Day-of-the-week, seasonality and long-term trends were analysed at national and regional levels (Wales, Scotland and the nine English Government Office Regions).

RESULTS

The long-term trend in daily accesses increases from 2.8 (95% confidence interval (CI): 2.6-3.0) per user on 1 January 2008 to 4.6 (95% CI: 4.3-4.9) on 31 December 2015, with small but significant differences in population-corrected accesses by region ( p < 0.001). There are statistically significant seasonal and day of the week patterns ( p < 0.001) across all regions. Accesses are 18% (95% CI: 14-22%) higher in summer than in January and at the weekend compared to weekdays in all regions; there is a 7.5% (95% CI: 6.1-8.9%) increase between Friday and Sunday.

CONCLUSIONS

There are consistent in-year patterns in access to TOXBASE indicating potential seasonal patterns in poisonings in Britain, with location-dependent rates of usage. This novel descriptive work lays the basis for future work on the interaction of TOXBASE use with emergency admission of patients into hospital.

Clinical Toxicology of Insecticides

Some insects compete for our food, some damage construction materials and some are important disease vectors in humans and animals. Hence, it is not surprising that chemicals (insecticides) have been developed that kill insects and other arthropods. More recently introduced insecticides, such as the neonicotinoids, have been produced with the intent that humans and animals will not be harmed by their appropriate use. This chapter reviews the clinical features and management of exposure to organophosphorus (OP) and carbamate insecticides, neonicotinoids, phosphides and pyrethroids. In the developing world where the ambient temperature is often high and personal protection equipment often not worn, poisoning particularly from OP and carbamate insecticides is common in an occupational setting, though more severe cases are due to deliberate ingestion of these pesticides. Both of these insecticides produce the cholinergic syndrome. The neonicotinoids, a major new class of insecticide, were introduced on the basis that they were highly specific for subtypes of nicotinic receptors that occur only in insect tissues. However, deliberate ingestion of substantial amounts of a neonicotinoid has resulted in features similar to those found in nicotine (and OP and carbamate) poisoning, though the solvent in some formulations may have contributed to their toxicity. Phosphides interact with moisture in air (or with water or acid) to liberate phosphine, which is the active pesticide. Inhalation of phosphine, however, is a much less frequent cause of human poisoning than ingestion of a metal phosphide, though the toxicity by the oral route is also due to phosphine liberated by contact of the phosphide with gut fluids. It is then absorbed through the alimentary mucosa and distributed to tissues where it depresses mitochondrial respiration by inhibiting cytochrome c oxidase and other enzymes. Dermal exposure to pyrethroids may result in paraesthesiae, but systemic toxicity usually only occurs after ingestion, when irritation of the gastrointestinal tract and CNS toxicity, predominantly coma and convulsions, result.

Use of oral dimercaptosuccinic acid (succimer) in adult patients with inorganic lead poisoning

BACKGROUND

Chelation therapy has been used as a means of reducing the body burden of lead for five decades. Intravenous sodium calcium edetate has been the preferred agent, but there is increasing evidence that dimercaptosuccinic acid (DMSA) is also a potent chelator of lead.

METHODS

Oral DMSA 30 mg/kg/day was administered to adults with blood lead concentrations > or = 50 microg/dl. The impact of DMSA on urine lead excretion, on blood lead concentrations and on symptoms was observed. The incidence and severity of adverse effects was also recorded.

RESULTS

Thirty-five courses were given to 17 patients. DMSA significantly (P < 0.0001) increased urine lead excretion and significantly (P < 0.0001) reduced blood lead concentrations. Mean daily urine lead excretion exceeded the pre-treatment value by a median of 12-fold with wide variation in response (IQR 8.9-14.8, 95% CI 10.1-14.6). Pre-treatment blood lead concentrations correlated well with 5-day urine lead excretion. Headache, lethargy and constipation improved or resolved in over half the patients within the first 2 days of chelation. DMSA was generally well tolerated, but one course was discontinued due to a severe mucocutaneous reaction. There was a transient increase in alanine aminotransferase (ALT) activity during 14% of chelations. DMSA caused a significant increase in urine copper (P < 0.0001) and zinc (P < 0.05) excretion.

CONCLUSION

Oral DMSA 30 mg/kg/day is an effective antidote for lead poisoning, though there is a wide inter- and intra-individual variation in response.