The New Paracetamol Guidelines

We have an update on the Management of Paracetamol Poisonings (MJA 203(5). 7 September 2015) (last update was in 2008) and it covers six main areas: Risk Assessment Charcoal Use Modified Release Paracetamol Large/Massive Ingestions Liquid paracetamol in children less than 6 years old. Consulting a Liver Transplant Unit - 

Some Notes:

• In children less than 6 years old, use ideal weight
• In children greater than 6 years old and in adults use actual weights to a maximum of 110kg
• Large doses are greater than 30g paracetamol
• Doses greater than 50g should be discussed with a toxicologist
• These guidelines apply to oral paracetamol- advice from toxicologist needed in IV paracetamol

RISK ASSESSMENT

​DOSE

​​Single dose over a period of <8 hours


​Repeated SUPRATHERAPEUTIC ingestion

​

​CHILDREN < 6yo​

​>200mg/kg


 
> 200mg/kg over a 24 hour period

 
>150mg/kg per 24 hour
period for preceding 48 hours
 
 

 
>100mg/kg  per 24 hour period for more than 24 hours

​​CHILDREN > 6yo and ADULTS 

​>200mg/kg or 10g (which ever is lower)


>200mg/kg or 10g (which ever is lower) over 24 hour period
 

 
>150mg/kg or 6g (which ever is lower)
per 24 hour period for preceding 48 hours

 
>100mg/kg or 4g/day (which ever is lower) per 24 hour period for more than 24 hours in those with symptoms of liver injury: abdo pain, nausea and vomiting

PARACETAMOL DOSING ASSOCIATED WITH HEPATIC INJURY

CHARCOAL USE

Single Dose Immediate release

• 50g of charcoal can be given up to 2 hours post ingestion
• If paracetamol dose is > 30g give charcoal up to 4 hours post ingestion

Modified release Paracetamol (i.e. panadol osteo)

• Can administer charcoal up to 4 hours post ingestion
• If paracetamol dose taken is >30g can benefit from charcoal at > 4hours post ingestion

MODIFIED RELEASE PARACETAMOL

As in the previous guideline treatment start Acetylceistine if > 200mg/kg or 10g has been ingested, given that two assessments of paracetamol concentration must be made 4 hours apart(the first being 4 hours post ingestion)

What has changed is when to discontinue acetylcysteine infusion

• paracetamol concentrations 4 hours apart must be below nomogram and decreasing
• continue infusion if ALT >50U/L or paracetamol is >10mg/L(66umol/L)

LARGE/MASSIVE INGESTIONS

• In those that ingest > 30g paracetamol, if the paracetamol level is twice the nomogram line, then double the concentration of the 16 hour infusion(no randomised control trials)
• Continue if at near completion of the 16 hour protocol the ALT>50U/L or paracetamol levels are >10mg/L or 66umol/L

LIQUID PARACETAMOL IN CHILDREN < 6 YEARS OLD

This only applies to well children who present at less than 4 hours post ingestion

CONSULTING A LIVER TRANSPLANT UNIT

​The following criteria need to be met:

• INR >3 at 48 hours of >4.5 at any time
• Oliguria or Creatinine > 200umol/L
• Persistent acidosis pH<7.3 or lactate >3mmol/L
• Systolic BP < 80mmHg despite resuscitation
• Hypoglycaemia
• Severe thrombocytopenia
• Encephalopathy