Intravenous paracetamol in paediatrics: cause for caution
- Madlen Gazarian, Anna Drew, Alexandra Bennett
- Aust Prescr 2014;37:24-5
- 3 February 2014
- DOI: 10.18773/austprescr.2014.007
A two-week-old 2.9 kg baby presented to a general hospital emergency department with acute bowel obstruction and underwent urgent laparotomy. Postoperatively the baby was given three doses of 290 mg intravenous paracetamol (instead of the prescribed 29 mg dose) over a 38-hour period. The error was detected 1–2 hours after the third dose, which was initially thought to be a single overdose. The preceding two overdoses were discovered six hours later and N-acetylcysteine was given, following the advice of a Poisons Information Centre toxicologist. The baby remained clinically stable and liver transaminases were normal throughout.
A 5.65 kg infant admitted to a general hospital was prescribed '80 mg paracetamol IV/PO/PR'. Poor legibility of the prescription led to interpretation of the dose as 280 mg. A 1000 mg vial of intravenous paracetamol was connected to an infusion pump set at 168 mL/hr for 10 minutes. The infusion continued beyond the intended duration and a total dose of 430 mg (75 mg/kg) was given.
Paracetamol has a good safety record when used appropriately. Since intravenous paracetamol became widely available there have been multiple inadvertent 10-fold overdoses in infants.1,2 A key contributing factor is the 10 mg/mL strength of intravenous paracetamol – health professionals mix up the mg and the mL dose. Ten-fold dosing errors occur regularly in paediatric patients and are a recognised source of significant harm, including deaths. A recent review examines contributing factors and recommends general strategies for harm prevention.3
The NSW Therapeutic Advisory Group (NSW TAG) has developed comprehensive, evidence-based guidance on the appropriate and safe use of intravenous paracetamol.1 There are key recommendations for clinicians caring for paediatric patients in all hospital settings. Importantly, NSW TAG's guidance provides an up-to-date dose recommendation for intravenous paracetamol in infants; this differs from the current Australian product information for infants weighing less than 10 kg. The justification for this 'off-label' dose recommendation is discussed.
NSW TAG's guidance also includes advice about using paracetamol for fever in adults with stroke, dosing in underweight adults and frail older people, and more general advice for preventing hepatotoxicity in adults.
vomiting or dehydration
severe hepatic impairment
* adapted from reference 1
Conflict of interest: none declared
Acknowledgements: Thanks to Jared Brown, Senior Poisons Specialist, and Dr Naren Gunja, Medical Director, NSW Poisons Information Centre, for their help with case identification. The valuable contribution of the NSW TAG Paracetamol Expert Advisory Group and the NSW TAG Editorial Committee to the development of NSW TAG's guidance document is also gratefully acknowledged.
Consultant in Paediatric Clinical Pharmacology and Therapeutics, NSW Therapeutic Advisory Group
Member, Editorial Committee, NSW Therapeutic Advisory Group
Honorary Associate Professor, University of NSW Sydney
Quality Use of Medicines Project officer, NSW Therapeutic Advisory Group
Co-Executive Officer, NSW Therapeutic Advisory Group