Print

Print


Let's not let this thread get out of hand...

As most of acetaminophen absorption seems to take place in the small intestine, delayed gastric emptying can, in fact, affect the time to peak and the peak plasma concentrations (There is a 1973 reference in this book chapter -- https://books.google.com/books?id=DO-7q2Vzz-AC&pg=PA115&lpg=PA115&dq=acetaminophen+absorption+full+stomach&source=bl&ots=k1mJBStV0s&sig=h6grVA-v992bUsNF0FO_d4p-J9A&hl=en&sa=X&ei=jS_hVLaOKYvvgwT_uoH4DA&ved=0CC4Q6AEwAzgK#v=onepage&q=acetaminophen%20absorption%20full%20stomach&f=false). However, some absorption does take place in the stomach.  The notion that an undetectable level at 2 hrs after ingestion is no safer than a level just below the treatment line on the nomagram is ludicrous.  100% certainty in anything is an awfully lofty goal, and one that is unlikely to be reached in any aspect of pediatric emergency medicine.  While we all love to have literature to point to when we make our decisions, the idea that having a paper or nomogram that supports your decision is 100% foolproof is a false premise.  Case in point...there are several published case reports of patients having had "safe" levels at 4 hours who then go on to have toxic levels later in their course  (http://www.researchgate.net/publication/51457726_Unexpected_late_rise_in_plasma_acetaminophen_concentrations_with_change_in_risk_stratification_in_acute_acetaminophen_overdoses).  

For those not comfortable with an undetectable level of 2 hours in a patient with low suspicion for toxic ingestion, answer me this: in a patient with a known ingestion of another substance, for whom we generally screen for co-ingestions with an APAP level (among others), if the level is zero, do you then check again after 4 hours to really be sure it's still zero? Or do you believe that first number and rule out an APAP co-ingestion?  


________________________________________
From: Pediatric Emergency Medicine Discussion List <[log in to unmask]> on behalf of Doc Holiday <[log in to unmask]>
Sent: Sunday, February 15, 2015 6:22 PM
To: [log in to unmask]
Subject: Possible Acetaminophen ingestion - level timing

In order to save me time, I am hoping someone would send me this evidence - it would be quite a help.
It would help me a lot if I could be sent those articles which show that if a level is zero or below X at 2 hours then there will be no toxic level at 4 hours and that this is not affected by whether the stomach is full or not at the time of supposed ingestion.
From what you write, you appear to have already looked carefully at this. Do you still have those articles to hand?
Thanks again!

From: [log in to unmask]
To: [log in to unmask]
Subject: RE: Possible Acetaminophen ingestion - level timing
Date: Sun, 15 Feb 2015 17:01:17 -0600

That language and attitude sets an impossibly high bar for evidence based medicine. In fact, it is tantamount to rationalizing that parachutes aren't needed because there is no published RCT supporting their use.Three people spouted dogma. Dr. Wilkerson cited a reference. At this point, as a disinterested party, I would say the preponderance of evidence favors early discharge if the 2 hr level is not detectable. Kevin Powell MD PhD FAAPPediatric hospitalistSaint Louis, MO
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html