Management of paracetamol poisoning

New recommendation for standard regimen of two acetylcysteine bags ab

Initial infusion

▪NAC 200 mg/kg (maximum 22 g) in glucose 5% 500 mL (child, 7 mL/kg up to 500 mL) or sodium chloride 0.9% 500 mL (child, 7 mL/kg up to 500 mL) intravenously, over 4 h.

Second NAC infusion

▪NAC 100 mg/kg (maximum 11 g) in glucose 5% 1000 mL (child, 14 mL/kg up to 1000 mL) or sodium chloride 0.9% 1000 mL (child, 14 mL/kg up to 1000 mL) intravenously, over 16 h b.

If ongoing NAC is required, continue at the rate of the second infusion (i.e., 100 mg/kg over 16 h). Higher ongoing infusion rates (i.e., 200 mg/kg over 16 h) may be required for massive paracetamol ingestions and a clinical toxicologist should be consulted c.

a NAC is also compatible with 0.45% saline + 5% dextrose. b For adults (aged ≥14 years), dosing should be based on actual body weight rounded up to the nearest 10 kg, with a ceiling weight of 110 kg. For children (aged < 14 years), actual body weight should be used. c If the initial paracetamol concentration was more than double the nomogram line following an acute ingestion, acetylcysteine dose should be increased to 200 mg/kg (maximum 22 g) in glucose 5% 1000 mL (child, 14 mL/kg up to 1000 mL) or sodium chloride 0.9% 1000 mL (child, 14 mL/kg up to 1000 mL) intravenously, over 16 h. Adapted from Chiew et al. (2020) [82].