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• Reply to : More blood tests in paracetamol overdose?
  Subramanian BK Mahadevan
  Published on: 9 January 2022
• More blood tests in paracetamol overdose?
  Ruth Owen
  Published on: 9 January 2022

• Published on: 9 January 2022

  Reply to : More blood tests in paracetamol overdose?

  • Subramanian BK Mahadevan, Consultant Paediatrician
  • Other Contributors:
    • Patrick McKiernan, Deirdre A Kelly. Liver Unit, Bimringham Children's Hospital, Bimringham

  Dear Editor,

  We welcome your interest in our paper(1) and in general agree with your comments. However, in our paper we wanted to emphasise the actions, which needed to be considered in the most severe cases.

  We agree that it is accepted practice not to perform further blood tests for those with paracetamol level below the treatment line at 4 hours post overdose and an overdose <150 mg/kg. However, t...

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  Dear Editor,

  We welcome your interest in our paper(1) and in general agree with your comments. However, in our paper we wanted to emphasise the actions, which needed to be considered in the most severe cases.

  We agree that it is accepted practice not to perform further blood tests for those with paracetamol level below the treatment line at 4 hours post overdose and an overdose <150 mg/kg. However, the time of ingestion is not always clear and paracetamol toxicity may follow multiple doses or chronic use(2). If there is any doubt about either of these and especially in younger children with viral infection receiving multiple doses we suggest that it is sensible to repeat liver function tests after 24 hours.

  We agree that in children who have taken paracetamol deliberatively should undergo a psychosocial review prior to discharge, so repeating liver function tests may not necessarily increase the hospital stay. Should it be appropriate that they be discharged within 24 hours, than a clinical judgement should be made on the need for repeat blood tests.

  It is correct that blood tests may be repeated at the end of NAC infusion.. But in those with the most severe illness especially where the INR is above 2, an early blood test at 12 hours may guide further management. This helps the team to contact a specialist liver centre for advice and referral and in severe cases, facilitates continuation of NAC without interruption.

  S B K Mahadevan
  P J McKiernan
  D A Kelly

  The Liver Unit
  Birmingham Children’s Hospital
  Steelhouse Lane
  Birmingham
  B4 6NH

  References:

  1) S B K Mahadevan, P J McKiernan, P Davies, and D A Kelly Paracetamol induced hepatotoxicity. Arch Dis Child 2006; 91:598-603.

  2) Heubi JE, Barbacci MB, Zimmerman HJ. Therapeutic misadventures with acetaminophen: hepatoxicity after multiple doses in children. J Pediatr. 1998;132(1):22-7.

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  Conflict of Interest:
  None declared.

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• Published on: 9 January 2022

  More blood tests in paracetamol overdose?

  • Ruth Owen, Paediatric SpR
  • Other Contributors:
    • Helen M Sammons, Consultant Paediatrician

  Dear Editor,

  We read with interest the recent article in Archives of Disease in Childhood concerning Paracetamol induced hepatotoxicity [1] and discussed it at Derbyshire Children’s Hospital’s Journal club. We found the management algorithm useful for knowing which patients we need to refer to a specialist unit.

  However, we felt that some clarification is needed regarding the issue of repeat blood tests i...

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  Dear Editor,

  We read with interest the recent article in Archives of Disease in Childhood concerning Paracetamol induced hepatotoxicity [1] and discussed it at Derbyshire Children’s Hospital’s Journal club. We found the management algorithm useful for knowing which patients we need to refer to a specialist unit.

  However, we felt that some clarification is needed regarding the issue of repeat blood tests in two situations.

  1. In Management A (paracetamol level below the treatment line and an overdose <150mg/kg) the authors suggests observation and repeat bloods in 24 hours. Our current practice, as guided by Toxbase [2], is not to do any further blood tests on children who do not require treatment. They stay in hospital to see CAMHS and are often discharged before 24 hours. They did not present any evidence for repeating blood tests in those not requiring N-acetylcysteine (NAC). This practice would increase our current admission times.

  2. Management B suggested blood tests 8-12 hourly whilst on NAC. Again our current practice is to perform blood tests at the end of the NAC, which is usually about 16 hours later. Depending on these blood results we make the decision whether to continue the NAC or not. We are not sure that performing blood tests sooner on all patients, or on some patients, and would this change our management.

  It would be helpful to know the evidence behind these issues.

  References:

  1. Mahadevan S, McKiernan P, Davies P, Kelly D. Paracetamol induced hepatotoxicity. Archives of Disease in Childhood. 2006; 91: 598-603.

  2. Toxbase, http://www.spib.axl.co.uk/toxbaseindex.htm Accessed 18 Sept 2006.

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  Conflict of Interest:
  None declared.

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