title: Delays during the administration of acetylcysteine for the treatment of paracetamol overdose.
abstract: The licensed intravenous acetylcysteine regimen for treating paracetamol overdose in most countries uses three separate infusions over 21 h. This complex regimen, requiring different infusion concentrations and rates, has been associated with administration errors. The aim of the present study was to assess the extent of administration delays occurring during this acetylcysteine regimen.
  
  
  
  A 6-month retrospective observational study was conducted at three English teaching hospitals with clinical toxicology services from October 2014. Patients aged 16 years and over, treated with intravenous acetylcysteine for paracetamol overdose, were included. The start times for infusions were recorded and the delays compared with the prescribed infusion times were calculated. Anaphylactoid reactions, intravenous cannula problems, overdose intent and smoking status were recorded to assess their contribution to delays.
  
  
  
  From 263 cases identified, 198 met the study inclusion criteria. The median time between the start of infusions 1 and 3 was delayed from the intended 5 h by a median (interquartile range) of 90 (50-163) min, with 135 (68%) cases delayed by more than 1 h. Significantly longer delays were observed in patients with anaphylactoid reactions [median delay 267 (217-413) min, n = 8] and accidental/supratherapeutic overdose [median delay 170 (95-260) min, n = 29]. There were no significant differences between smokers and nonsmokers, or for patients with intravenous cannula problems.
  
  
  
  Long delays were identified during the three-infusion acetylcysteine regimen for the treatment of paracetamol overdose. These were of clinical significance and could lead to periods of subtherapeutic plasma acetylcysteine concentrations and potentially avoidable hepatotoxicity, as well as delaying hospital discharge.
authors.affiliation: Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.|Emergency Department, St Mary's Hospital, Imperial College NHS Trust, London, UK.
authors.forename: George P
authors.initials: GP
authors.lastname: Bailey
authors.affiliation: Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
authors.forename: Javad
authors.initials: J
authors.lastname: Najafi
authors.affiliation: Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
authors.forename: Muhammad E M O
authors.initials: ME
authors.lastname: Elamin
authors.affiliation: York Teaching Hospital NHS Foundation Trust, York, UK.
authors.forename: W Stephen
authors.initials: WS
authors.lastname: Waring
authors.affiliation: Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.|Medical Toxicology Centre, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
authors.forename: Simon H L
authors.initials: SH
authors.lastname: Thomas
authors.affiliation: Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.|Faculty of Life Sciences and Medicine, King's College London, London, UK.
authors.forename: John R H
authors.initials: JR
authors.lastname: Archer
authors.affiliation: Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK.|Faculty of Life Sciences and Medicine, King's College London, London, UK.
authors.forename: David M
authors.initials: DM
authors.lastname: Wood
authors.affiliation: Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust and King's Health Partners, London, UK. paul.dargan@gstt.nhs.uk.|Faculty of Life Sciences and Medicine, King's College London, London, UK. paul.dargan@gstt.nhs.uk.
authors.forename: Paul I
authors.initials: PI
authors.lastname: Dargan
mesh_terms: D000082:Acetaminophen / Q000506:poisoning*; D000111:Acetylcysteine / Q000008:administration & dosage* / Q000627:therapeutic use*; D000293:Adolescent; D000328:Adult; D000931:Antidotes / Q000008:administration & dosage / Q000627:therapeutic use; D004334:Drug Administration Schedule; D062787:Drug Overdose / Q000188:drug therapy*; D005260:Female; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008508:Medication Errors; D012189:Retrospective Studies; D013997:Time Factors; D055815:Young Adult
chemical_list: D000931:Antidotes; D000082:Acetaminophen; D000111:Acetylcysteine
keywords: acetaminophen overdose; acetylcysteine; drug administration; intravenous infusions; paracetamol overdose