ÖZET

Giriş:

Akut parasetamol zehirlenmesi (APİ) ile başvuran çocuklarda aldığı bildirilen parasetamol dozu (BPD) ile kan parasetamol düzeyini karşılaştırmak ve sevk edilen hastalarda N-asetilsistein (NAC) uygulama endikasyonlarını araştırmaktır.

Yöntemler:

Çalışmamız üçüncü basamak bir hastanenin çocuk acil servisinde (AS) Haziran 2015-Haziran 2019 tarihleri arasında APİ olan çocuklarda geriye dönük olarak yapılmıştır. Demografik özellikler, zehirlenmelerin nedenleri, BPD (mg/kg) ve kan parasetamol düzeyleri (8-4-12-16. ve/veya 24. saatte) değerlendirildi. Antidot ve AS'ye sevk endikasyonu için BPD >150 mg/kg olarak kabul edildi.

Bulgular:

Toplamda 117 akut APİ olgusu incelendi. Hastaların yaş ortalaması 8,97 (±6,0) yıl ve %68,3’ü kızdı. Ortanca BPD dozu 2725 mg (ortalama 138±51,9 mg/kg) idi. Ergenlerde BPD miktarlara daha küçük çocuklara göre anlamlı derecede daha yüksekti (p<0.001). Hastaların %88,9’una 4. saat KPD görülürken; 8., 12., 16. ve 24. saatte sırasıyla hastaların %11,1, %9,4, %3,5 ve %3,5’inde KPD bakılmıştı. Sevk edilenlerin sadece 34/66’sında BPD >150 mg/kg olmasına rağmen, ilk merkezdeki hekimler aktif kömür (%90,9), gastrik yıkama işlemi (%68) ve damar içi NAC (%48) uygulama eğilimindeydiler. Hekimlerin üçüncü basamağa sevk etmeden önce BPD >150 mg/kg olması durumunda NAC kullandığı görüldü (p=0,001).

Sonuç:

NAC endikasyonunu belirlemek için BPD kullanılmamalıdır. Antidot kullanımı, kan parasetamol düzeyi bakılamayan merkezlerde veya ilk 8 saat içinde üst merkeze sevk edilemeyecek hastalarda kullanılmalıdır.

References

Marzuillo P, Guarino S, Barbi E. Paracetamol: a focus for the general pediatrician. Eur J Pediatr. 2014;173:415-25.

Acheampong P, Thomas SH. Determinants of hepatotoxicity after repeated supratherapeutic paracetamol ingestion: systematic review of reported cases. Br J Clin Pharmacol. 2016;82:923-31.

Heard K, Anderson V, Dart RC, Kile D, Lavonas EJ, et al. Serum Acetaminophen Protein Adduct Concentrations in Pediatric Emergency Department Patients. J Pediatr Gastroenterol Nutr. 2017;64:533-5.

Gummin DD, Mowry JB, Spyker DA, Brooks DE, Beuhler MC, et al. 2018 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 36th Annual Report. Clin Toxicol (Phila). 2019;57:1220-413.

Yesil Y, Ozdemir AA. Evaluation of the children with acute acetaminophen overdose and intravenous N-acetylcysteine treatment. Pak J Med Sci. 2018;34:590-4.

Antoine DJ, Dear JW. How to treat paracetamol overdose and when to do it. Expert Rev Clin Pharmacol. 2016;9:633-5.

Chiew AL, Isbister GK, Duffull SB, Buckley NA. Evidence for the changing regimens of acetylcysteine. Br J Clin Pharmacol. 2016;81:471-81.

Buckley NA, Whyte IM, O'Connell DL, Dawson AH. Activated charcoal reduces the need for N-acetylcysteine treatment after acetaminophen (paracetamol) overdose. J Toxicol Clin Toxicol. 1999;37:753-7.

Yarema MC, Green JP, Sivilotti ML, Johnson DW, Nettel-Aguirre A, et al. Can a serum acetaminophen concentration obtained less than 4 hours post-ingestion determine which patients do not require treatment with acetylcysteine?. Clin Toxicol (Phila). 2017;55:102-8.

Fisher ES, Curry SC. Evaluation and treatment of acetaminophen toxicity. Adv Pharmacol. 2019;85:263-72.

Chiew AL, Gluud C, Brok J, Buckley NA. Interventions for paracetamol (acetaminophen) overdose. Cochrane Database Syst Rev. 2018;2:CD003328.

Marzullo L. An update of N-acetylcysteine treatment for acute acetaminophen toxicity in children. Curr Opin Pediatr. 2005;17:239-45.

Lewis RK, Paloucek FP. Assessment and treatment of acetaminophen overdose. Clin Pharm. 1991;10:765-74.

Rumack BH, Matthew H. Acetaminophen poisoning and toxicity. Pediatrics. 1975;55:871-6.

CDER-PHRMA-AASLD Conference, clinical white paper, preconference study document before conference. “Drug-Induced Liver Injury: A National and Global Problem.” Available from: https://www.fda.gov/media/116737/download.

Jiménez-Gómez JPMB, Donat-Aliaga E. Acute hepatic failure. Spanish Society of Gastroenterology, Hepatology and Pediatric Nutrition, eds Diagnostic-therapeutic protocols of gastroenterology, hepatology and nutrition pediatric. 1st ed. ed. Madrid, Spain: ERGON; 2010:97-205.

Lin YR, Liu TH, Liu TA, Chang YJ, Chou CC, et al. Pharmaceutical poisoning exposure and outcome analysis in children admitted to the pediatric emergency department. Pediatr Neonatol. 2011;52:11-7.

Mintegi S, Fernández A, Alustiza J, Canduela V, Mongil I, et al. Emergency visits for childhood poisoning: a 2-year prospective multicenter survey in Spain. Pediatr Emerg Care. 2006;22:334-8.

Azkunaga B, Mintegi S, Salmón N, Acedo Y, Del Arco L, et al. Intoxicaciones en menores de 7 años en España. Aspectos de mejora en la prevención y tratamiento [Poisoning in children under age 7 in Spain. Areas of improvement in the prevention and treatment]. An Pediatr (Barc). 2013;78:355-60.

Seifert SA, Kirschner RI, Martin TG, Schrader RM, Karowski K, et al. Acetaminophen concentrations prior to 4 hours of ingestion: impact on diagnostic decision-making and treatment. Clin Toxicol (Phila). 2015;53:618-23.

Kominek K, Pawłowska-Kamieniak A, Mroczkowska-Juchkiewicz A, Krawiec P, Pac-Kożuchowska E. Intentional and accidental paracetamol poisoning in childhood - a retrospective analysis. Postepy Hig Med Dosw (Online). 2015;69:452-6.

Chiew AL, Domingo G, Buckley NA, Stathakis P, Ress K, et al. Hepatotoxicity in a child following an accidental overdose of liquid paracetamol. Clin Toxicol (Phila). 2020;58:1063-6.

Rumack BH, Bateman DN. Acetaminophen and acetylcysteine dose and duration: past, present and future. Clin Toxicol (Phila). 2012;50:91-8.

Bateman DN, Carroll R, Pettie J, Yamamoto T, Elamin ME, et al. Effect of the UK's revised paracetamol poisoning management guidelines on admissions, adverse reactions and costs of treatment. Br J Clin Pharmacol. 2014;78:610-8.

Chiew AL, Isbister GK, Kirby KA, Page CB, Chan BSH, et al. Massive paracetamol overdose: an observational study of the effect of activated charcoal and increased acetylcysteine dose (ATOM-2). Clin Toxicol (Phila). 2017;55:1055-65.

Waring WS, Stephen AF, Robinson OD, Dow MA, Pettie JM. Lower incidence of anaphylactoid reactions to N-acetylcysteine in patients with high acetaminophen concentrations after overdose. Clin Toxicol (Phila). 2008;46:496-500.

Duffull SB, Isbister GK. Predicting the requirement for N-acetylcysteine in paracetamol poisoning from reported dose. Clin Toxicol (Phila). 2013;51:772-6.

Schmidt LE, Dalhoff K, Poulsen HE. Acute versus chronic alcohol consumption in acetaminophen-induced hepatotoxicity. Hepatology. 2002;35:876-82.

Alındığı İddia Edilen Parasetamol Dozunun Kan Parasetamol Düzeyleri ile Karşılaştırılması ve N-Asetilsistein Kullanımı ile İlişkisi: 117 Hasta ile Geriye Dönük Bir Çalışma

ÖZET

References