Lecture 6
Help!
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| Treatment Plan | Emergency stabilization
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Decontamination (don’t worry about it b/c of antidote)
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Antidote
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Enhancing elimination
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Liver transplant
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| APAP Treatments (3) |
Emergency stabilization
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Decontamination
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Acetylcysteine (^-acetylcysteine, NAC, Mucomyst , Acetadote )
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| Acetylcysteine (NAC) Available Forms | Acetadote – IV
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Mucomyst – Inhalation/Oral (generic)
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| Muco myst | Inhalation/Oral (generic)
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| Acetadote | IV
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| NAC MOA My notes | Precursor for glutathione synthesis
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Substitute for glutathione
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Substrate for sulfation
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Direct hepato protective
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| When NAC most effective | within first 8 hours
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| Acetylcysteine Effectiveness | Equally effective if given within the first 8 hours
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Effectiveness decreases after 8 hours
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? Effective > 24 hours
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Some benefit late in fulminant hepatic fail
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| NAC Indications | Acute overdose
[APAP] above treatment line
Elevated AST/ALT or [APAP] if time unknown
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Chronic overdose
High risk based on symptoms and/or [APAP],
AST/ALT
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| NAC Indications Acute OD - time known | [APAP]
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| NAC Indications Acute OD - time unknown | Increased AST/ALT (>50IU/L)
Increased (APAP] (> lOmcg/mL)
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| NAC Indications Chronic OD | High-risk
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Symptoms
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[APAP]
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AST/ALT
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| NAC Oral dose | Load followed by maintenance
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| NAC Oral dose Load | 140 mg/kg load
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| NAC Oral dose Maintenance | 70 mg/kg q4 hours for 17 doses
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| NAC Oral administration |
Dilute to 5% solution to avoid gastric irritation
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| Oral Acetylcysteine (NAC) Notes Dose | 140 mg/kg load
M 70 mg/kg q4 hours X 17
Shorter course may be used
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| 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
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| NAC Oral SEs | Primarily GI
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| IV Acetylcysteine (NAC) Adults Loading Dose | 150 mg/kg in 200mL D5W over 60 min
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| IV Acetylcysteine (NAC) Adults Loading Dose J Maintenance Dose | 50 mg/kg in 500mL D5W over 4 hours 4
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100 mg/kg in 100mL D5W over 16 hours
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| IV Acetylcysteine (NAC) Children | 20kg, < 40 kg
Decrease fluid volume by 50%
< 20 kg
Fluid adjusted by body weight (see ???)
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| NAC Pediatric considerations | Risk for anaphylactoid reactions
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Higher risk in asthamtics
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Hyponatremia in children if pediatric fluid guidelines not adhered
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| NAC Monitoring therapy | Check AST/ALT and [APAP] at end of infusion or oral therapy
Continue therapy if detectable APAP or AST/AST increasing
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| Ensuring Optimal NAC Therapy Obtain | APAP, AST & ALT concentrations at end of infusion
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| Ensuring Optimal NAC Therapy Continue NAC if |
detectable APAP or rising AST/ALT (16-hour bag)
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| Ensuring Optimal NAC Therapy At risk for longer duration of therapy: |
Late presenters
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Supra-therapeutic or unknown ingestion
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Diphenhydramine
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| APAP Liver transplant Kings College criteria pH | < 7.3
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| APAP Liver transplant Kings College criteria lactate | > 3 mmol/L
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| APAP Liver transplant Kings College criteria INR | >6.5
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| APAP Liver transplant Kings College criteria Scr | >3.39mg/dL
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| APAP Liver transplant Kings College criteria encephalopathy | Grade III or higher
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