Non-Intentional N-Acetylcysteine Overdose Associated with Cerebral Edema and Brain Death
N-acetylcysteine is the established treatment for acetaminophen toxicity. This medication’s complex dosing schedule engenders a high incidence of medication errors. While nuisance side effects are common, only rare case reports describe serious outcomes associated with N-acetylcysteine administratio...
| Main Authors: | , , , , |
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| Format: | Article |
| Language: | English |
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Karger Publishers
2023-02-01
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| Series: | Case Reports in Gastroenterology |
| Subjects: | |
| Online Access: | https://www.karger.com/Article/FullText/529169 |
| _version_ | 1811161422455898112 |
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| author | Emma E.M. Spence Sey Shwetz Lauren Ryan Natalie Anton Ari R. Joffe |
| author_facet | Emma E.M. Spence Sey Shwetz Lauren Ryan Natalie Anton Ari R. Joffe |
| author_sort | Emma E.M. Spence |
| collection | DOAJ |
| description | N-acetylcysteine is the established treatment for acetaminophen toxicity. This medication’s complex dosing schedule engenders a high incidence of medication errors. While nuisance side effects are common, only rare case reports describe serious outcomes associated with N-acetylcysteine administration, all of which take place in the setting of non-intentional N-acetylcysteine overdose. This case report contributes to a small but growing literature that suggests that large N-acetylcysteine overdose may have devastating outcomes. We describe a 15-year-old female who presented with stage III acetaminophen toxicity and who received a non-intentional 6-fold overdose of intravenous N-acetylcysteine due to a medication prescribing error. During the N-acetylcysteine infusion dosing error, the patient had clinical deterioration including seizure followed by cerebral edema and brain herniation that progressed to brain death. She developed agitation and worsening headache within 2 h of the dosing error, which progressed to seizure and intubation 14 h into the dosing error. Although possibly due to hepatic encephalopathy, at the time she developed fixed dilated pupils, her lactate, international normalized ratio, aspartate aminotransferase, and alanine aminotransferase had all improved. On review of the literature, other case reports of seizures (n = 4) and cerebral edema with brain herniation (n = 3) were found, suggesting our patient was not an isolated case. Clinicians need to be aware of the common occurrence of dosing errors for N-acetylcysteine infusions. We suggest institutions review their N-acetylcysteine ordering, dosing, and mixing protocols in order to avoid similar rare errors in the future. Iatrogenic overdose of N-acetylcysteine can cause seizure, cerebral edema, and brain death. |
| first_indexed | 2024-04-10T06:15:01Z |
| format | Article |
| id | doaj.art-4c37cc9f65384d42a99435fd2e3ae2d7 |
| institution | Directory Open Access Journal |
| issn | 1662-0631 |
| language | English |
| last_indexed | 2024-04-10T06:15:01Z |
| publishDate | 2023-02-01 |
| publisher | Karger Publishers |
| record_format | Article |
| series | Case Reports in Gastroenterology |
| spelling | doaj.art-4c37cc9f65384d42a99435fd2e3ae2d72023-03-02T10:03:56ZengKarger PublishersCase Reports in Gastroenterology1662-06312023-02-011719610310.1159/000529169529169Non-Intentional N-Acetylcysteine Overdose Associated with Cerebral Edema and Brain DeathEmma E.M. Spence0https://orcid.org/0000-0003-3307-8923Sey Shwetz1Lauren Ryan2Natalie Anton3Ari R. Joffe4Internal Medicine Residency Program, University of Calgary Cumming School of Medicine, Calgary, AB, CanadaDepartment of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, CanadaDivision of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alberta and Stollery Children’s Hospital, Edmonton, AB, CanadaDivision of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alberta and Stollery Children’s Hospital, Edmonton, AB, CanadaDivision of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alberta and Stollery Children’s Hospital, Edmonton, AB, CanadaN-acetylcysteine is the established treatment for acetaminophen toxicity. This medication’s complex dosing schedule engenders a high incidence of medication errors. While nuisance side effects are common, only rare case reports describe serious outcomes associated with N-acetylcysteine administration, all of which take place in the setting of non-intentional N-acetylcysteine overdose. This case report contributes to a small but growing literature that suggests that large N-acetylcysteine overdose may have devastating outcomes. We describe a 15-year-old female who presented with stage III acetaminophen toxicity and who received a non-intentional 6-fold overdose of intravenous N-acetylcysteine due to a medication prescribing error. During the N-acetylcysteine infusion dosing error, the patient had clinical deterioration including seizure followed by cerebral edema and brain herniation that progressed to brain death. She developed agitation and worsening headache within 2 h of the dosing error, which progressed to seizure and intubation 14 h into the dosing error. Although possibly due to hepatic encephalopathy, at the time she developed fixed dilated pupils, her lactate, international normalized ratio, aspartate aminotransferase, and alanine aminotransferase had all improved. On review of the literature, other case reports of seizures (n = 4) and cerebral edema with brain herniation (n = 3) were found, suggesting our patient was not an isolated case. Clinicians need to be aware of the common occurrence of dosing errors for N-acetylcysteine infusions. We suggest institutions review their N-acetylcysteine ordering, dosing, and mixing protocols in order to avoid similar rare errors in the future. Iatrogenic overdose of N-acetylcysteine can cause seizure, cerebral edema, and brain death.https://www.karger.com/Article/FullText/529169n-acetylcysteinecase reportoverdosemedication errorquality improvement |
| spellingShingle | Emma E.M. Spence Sey Shwetz Lauren Ryan Natalie Anton Ari R. Joffe Non-Intentional N-Acetylcysteine Overdose Associated with Cerebral Edema and Brain Death Case Reports in Gastroenterology n-acetylcysteine case report overdose medication error quality improvement |
| title | Non-Intentional N-Acetylcysteine Overdose Associated with Cerebral Edema and Brain Death |
| title_full | Non-Intentional N-Acetylcysteine Overdose Associated with Cerebral Edema and Brain Death |
| title_fullStr | Non-Intentional N-Acetylcysteine Overdose Associated with Cerebral Edema and Brain Death |
| title_full_unstemmed | Non-Intentional N-Acetylcysteine Overdose Associated with Cerebral Edema and Brain Death |
| title_short | Non-Intentional N-Acetylcysteine Overdose Associated with Cerebral Edema and Brain Death |
| title_sort | non intentional n acetylcysteine overdose associated with cerebral edema and brain death |
| topic | n-acetylcysteine case report overdose medication error quality improvement |
| url | https://www.karger.com/Article/FullText/529169 |
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