Question | Answer |
Treatment Plan | Emergency stabilization
,
Decontamination (don’t worry about it b/c of antidote)
,
Antidote
,
Enhancing elimination
,
Liver transplant |
APAP Treatments
(3) | Emergency stabilization
,
Decontamination
,
Acetylcysteine (^-acetylcysteine, NAC, Mucomyst , Acetadote ) |
Acetylcysteine (NAC)
Available Forms | Acetadote – IV
,
Mucomyst – Inhalation/Oral (generic) |
Muco myst | Inhalation/Oral (generic) |
Acetadote | IV |
NAC MOA
My notes | Precursor for glutathione synthesis
,
Substitute for glutathione
,
Substrate for sulfation
,
Direct hepato protective |
When NAC most effective | within first 8 hours |
Acetylcysteine Effectiveness | Equally effective if given within the first 8 hours
,
Effectiveness decreases after 8 hours
,
? Effective > 24 hours
,
Some benefit late in fulminant hepatic fail |
NAC Indications | Acute overdose
[APAP] above treatment line
Elevated AST/ALT or [APAP] if time unknown
,
Chronic overdose
High risk based on symptoms and/or [APAP],
AST/ALT |
NAC Indications
Acute OD - time known | [APAP] |
NAC Indications
Acute OD - time unknown | Increased AST/ALT (>50IU/L)
Increased (APAP] (> lOmcg/mL) |
NAC Indications
Chronic OD | High-risk
,
Symptoms
,
[APAP]
.
AST/ALT |
NAC Oral dose | Load followed by maintenance |
NAC Oral dose Load | 140 mg/kg load |
NAC Oral dose Maintenance | 70 mg/kg q4 hours for 17 doses |
NAC Oral administration | Dilute to 5% solution to avoid gastric irritation |
Oral Acetylcysteine (NAC) Notes
Dose | 140 mg/kg load
M 70 mg/kg q4 hours X 17
Shorter course may be used |
Oral Acetylcysteine (NAC) Notes
Administration | Dilute to 5% solution to avoid gastric irritation
Cold, sweet, acidic beverage to disguise taste - FRESCA™
NG/NJ
Smaller more frequent doses |
NAC Oral SEs | Primarily GI |
IV Acetylcysteine (NAC)
Adults
Loading Dose | 150 mg/kg in 200mL D5W over 60 min |
IV Acetylcysteine (NAC)
Adults
Loading Dose J
Maintenance Dose | 50 mg/kg in 500mL D5W over 4 hours 4
,
100 mg/kg in 100mL D5W over 16 hours |
IV Acetylcysteine (NAC)
Children | 20kg, < 40 kg
Decrease fluid volume by 50%
< 20 kg
Fluid adjusted by body weight (see ???) |
NAC
Pediatric considerations | Risk for anaphylactoid reactions
,
Higher risk in asthamtics
,
Hyponatremia in children if pediatric fluid guidelines not adhered |
NAC
Monitoring therapy | Check AST/ALT and [APAP] at end of infusion or oral therapy
Continue therapy if detectable APAP or AST/AST increasing |
Ensuring Optimal NAC Therapy
Obtain | APAP, AST & ALT concentrations at end of infusion |
Ensuring Optimal NAC Therapy
Continue NAC if | detectable APAP or rising AST/ALT (16-hour bag) |
Ensuring Optimal NAC Therapy
At risk for longer duration of therapy: | Late presenters
, ,
Supra-therapeutic or unknown ingestion
, ,
Diphenhydramine |
APAP Liver transplant
Kings College criteria
pH | < 7.3 |
APAP Liver transplant
Kings College criteria
lactate | > 3 mmol/L |
APAP Liver transplant
Kings College criteria
INR | >6.5 |
APAP Liver transplant
Kings College criteria
Scr | >3.39mg/dL |
APAP Liver transplant
Kings College criteria
encephalopathy | Grade III or higher |