title: Massive acetaminophen ingestion with early metabolic acidosis and coma: treatment with IV NAC and continuous venovenous hemodiafiltration.
abstract: BACKGROUND
  We report the extraction of acetaminophen by continuous venovenous hemodiafiltration (CVVHD) during treatment of an acute ingestion of 200 g with a peak recorded serum acetaminophen level of 1,614 mg/L (10,652 micromol/L).
  
  
  METHODS
  The patient presented with early onset of coma, metabolic acidosis, and hypotension in the absence of significant hepatic injury. In addition to N-acetylcysteine (NAC) therapy, CVVHD was performed to manage the acid-base disturbance. Flow rate, effluent volume, and serum and effluent drug concentrations were obtained at hourly intervals. During 16 h of CVVHD the acetaminophen level dropped from 1,212 to 247 mg/L.
  
  
  CONCLUSIONS
  The average clearance of acetaminophen by CVVHD was 2.53 L/h, with removal of 24 g of acetaminophen over 16 h. As NAC is effective in preventing hepatic injury after acute acetaminophen overdose, the role of dialysis or CVVHD is limited.
authors.affiliation: Department of Medicine and Emergency Medicine, Maine Medical Center and Northern New England Poison Center, 901 Washington Avenue, Portland, ME 04102, USA. wiegat@mmc.org
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Wiegand
authors.forename: Mary
authors.initials: M
authors.lastname: Margaretten
authors.forename: Kent R
authors.initials: KR
authors.lastname: Olson
mesh_terms: D000082:Acetaminophen / Q000097:blood / Q000506:poisoning*; D000111:Acetylcysteine / Q000627:therapeutic use*; D000138:Acidosis / Q000139:chemically induced; D018712:Analgesics, Non-Narcotic / Q000097:blood / Q000506:poisoning*; D000931:Antidotes / Q000627:therapeutic use; D003128:Coma / Q000139:chemically induced; D003131:Combined Modality Therapy; D062787:Drug Overdose; D005260:Female; D017583:Hemodiafiltration / Q000379:methods*; D006801:Humans; D007022:Hypotension / Q000139:chemically induced; D055815:Young Adult
chemical_list: D018712:Analgesics, Non-Narcotic; D000931:Antidotes; D000082:Acetaminophen; D000111:Acetylcysteine