TITLE:
Potentially life-threatening intravenous acetaminophen overdose in a 3-month-old (40 weeks’ post-menstrual age), 2.3 kg baby girl
AUTHORS:
Shane Campbell, Thomas Engelhardt, James McLay, Brian Anderson
KEYWORDS:
Neonate; Acetaminophen Overdose; No Sequelae; PK Models; Drug Error
JOURNAL NAME:
Open Journal of Pediatrics,
Vol.3 No.3,
August
15,
2013
ABSTRACT:
A case is presented of a
serious, potentially life-threatening intravenous acetaminophen overdose in a
3-month-old (40 weeks’ post menstrual age),2.3 kgbaby girl. The
neonate was scheduled for urgent laser therapy for retinopathy of prematurity.
Instead of an intended intravenous Hartmann’s solution bolus of 10 ml·kgˉ1,
the neonate received a 17 ml bolus of correctly labelled intravenous 1%
acetaminophen. The National Poisons Bureau was immediately contacted for advice
and in the absence of data suggested a treatment with N-acetylcysteine for a
24-hour period. Baseline blood samples for clotting, liver function, urea and
electrolytes, full blood count and plasma acetaminophen concentration were
taken 30 min, 8.25 h, 12.5 h, 18.5 h and 120 h after the overdose. Acetaminophen
concentration was 78 mg·Lˉ1 at
30 min, but it was undetectable at any other time. Using a recent and complete
PK-PD dataset we are able to show that the measured plasma acetaminophen concentration
fits well on PK estimates for acetaminophen in this neonate. The
non-detectable (low) plasma acetaminophen concentration at >8 h is also
consistent with this model, especially if clearance is slightly increased in
the premature nursery graduate. Medical errors are rarely the fault of an individual and
they are often due to a combination of factors. Contributing factors, in this
case, are described under the following headings: Catalyst event, system fault,
loss of situational awareness, and human error.