Summary of articles
- This article is a double-blind, randomized study, which include 217 patients in total who overdose on acetaminophen
- Purpose of this study: To assess whether adverse effects can be reduced with either a shorter modified acetylcysteine use or use of antiemetic pretreatment with ondansetron, or both
- Method: 217 patients are randomized into 4 groups
- Group 1: n=55, ondansetron and modified acetylcysteine
- Group 2: n=56, ondansetron and standard acetylcysteine
- Group 3: n=55, placebo and modified acetylcysteine
- Group 4: n=56, placebo and standard acetylcysteine
- So, for modified acetylcysteine total=108 patients, and for standard acetylcysteine total=109 patients, receive ondansetron total=109 patients, and receive placebo total=108 patients
The placebo use: infusion of 5% dextrose or saline
At 2 hours of treatments, adverse effects, like vomiting, retching, need for rescue antiemetic treatment, and anaphylactoid reactions were recorded as primary outcome. And ALT levels were recorded as secondary outcome
- Results:
Primary outcomes (treatment start for 0-2 hours)
- In modified acetylcysteine, there are 39/108 patients record vomiting, retching and need antiemetic treatment
- In standard acetylcysteine, there are 71/109 patients record vomiting, retching and need antiemetic treatment (adjusted odds ratio 0·26, 97·5% CI; p<0·0001)
- In receiving ondansetron, 45/109 patients record vomiting, retching and need antiemetic treatment
- In receiving placebo, 65/108 patients record vomiting, retching and need antiemetic treatment(adjusted odds ratio 0·41, 97·5% CI; p=0·003)
- Anaphylactoid reactions: 5 patients in modified group, and 31 patients in the standard group (adjusted common odds ratio 023, 97·5% CI; p<0·0001)
Secondary outcomes (treatment start for 0-12 hours)
- In modified acetylcysteine, there are 60 patients record vomiting, retching and need antiemetic treatment
- In standard acetylcysteine, there are 80 patients record vomiting, retching and need antiemetic treatment(adjusted odds ratio 0·37, 97·5% CI; p=0.003)
- In receiving ondansetron, 58 patients record vomiting, retching and need antiemetic treatment
- In receiving placebo, 82 patients record vomiting, retching and need antiemetic treatment(adjusted odds ratio 0·35, 97·5% CI; p=0·002)
- In modified acetylcysteine, there are 9 patients have 50% increase in AST levels
- In standard acetylcysteine, there are 13 patients have 50% increase in AST levels (adjusted odds ratio 0·60, 97·5% CI; p=0.003)
- In receiving ondansetron, there are 16 patients have 50% increase in AST levels
- In receiving placebo, there are 6 patients have 50% increase in AST levels (adjusted odds ratio 3·30, 97·5% CI; p=0·024)
- Conclusion
In patients who overdose on acetaminophen, a 12 hours modified acetylcysteine regimen has less adverse events and fewer anaphylactoid reactions
- Relating to my patient
My patient, Ms. Liu was started on acetylcysteine per poison control, she is treated with acetylcysteine 21 hours protocol, with 7.84g/5.22g/2.62g, and according to nurse’s note, the plan of care, patient felt nausea and vomit twice during the NAC treatment. So, what if patient can have shorter modified acetylcysteine treatment, 12 hours, and there will be less adverse events
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