792 Improving safety and care of children with paracetamol overdose referred to a tertiary liver unit

Abstract

<h3>Aims</h3> Paracetamol Overdose (POD) is the most common drug reported either as intentional or accidental ingestion. Majority are easily managed with advice available on TOXBASE or National Poison Information Service. There are no established guidelines in the United Kingdom for persistently abnormal liver function tests after the completion of recommended N-acetylcysteine (NAC) infusions, prompting referrals to the Liver Unit. We reviewed the referrals received by the Liver Unit with the aim of determining: (a) Reason for referral/seeking advice (b) consistency of specialist advice provided to the referrer, (c) Criteria for transfer to the liver unit and (d) Use the above information and literature review to develop a protocol focusing on advice for liver dysfunction following completion of NAC infusions recommended by TOXBASE and setting criteria for transferring the child to the Liver Unit. <h3>Methods</h3> This is a single-center retrospective review of referrals received for POD in children aged ≤ 16 years, over a 2-year period (01 January 2020 to 21 December 2021). Data was retrieved from the National On-call Referral System (NORSe) used by the Liver Unit to log referrals. <h3>Results</h3> 89 referrals were received over the 2-year period. The demographics of the patients and details of the referrals are summarised in table 1. The most common reasons for referrals were for coagulopathy with prothrombin time (PT) &gt; 15 seconds or International Normalised Ratio (INR)&gt; 1.3 (n= 68) and deranged liver transaminases with levels &gt; upper limit of normal (ULN) (n= 80). Specialist advice from the liver unit was consistent for all queries on coagulopathy advising intravenous (IV) vitamin K, continuation of NAC with clinical and blood test monitoring. Of the 68 patients with coagulopathy, 14 (16%) had PT &gt; 20 seconds and INR &gt; 2 (range PT 21-38.7, INR 2.1- 3.8) fulfilling criteria for paediatric acute liver failure (PALF). Of these, 7 patients were accepted for transfer (range PT 22- 38.7, INR 2.4- 3.8) while the rest were treated locally. However, there were no clear criteria for transfer of a child with POD induced PALF to the tertiary liver unit The advice was variable in all referrals in regards to stopping NAC in children with deranged liver transaminases with normal coagulation profile. A protocol was subsequently developed, taking the above information into consideration (figure 1). <h3>Conclusion</h3> Majority of the referrals sought the liver unit’s input for coagulopathy and elevated liver transaminases after completion of the NAC infusions as per TOXBASE protocol. The proposed protocol will seek to help in providing consistent advice and criteria for transfer, thereby providing safe care for children with POD locally while utilising the specialist services optimally and timely. <h3>References</h3> National Poisons Information Service. TOXBASE. Paracetamol. 2017 [internet publication]. Whyte, Ian M et al. ‘Effect of paracetamol poisoning on international normalised ratio.’ <i>Lancet (London, England).</i> 2003; 361(9355):429. doi:10.1016/S0140-6736(03)12401-4 Shah, Anoop D et al. Understanding lactic acidosis in paracetamol (acetaminophen) poisoning. <i>British Journal of Clinical Pharmacology.</i> 2011;71(1): 20-8. doi:10.1111/j.1365-2125.2010.03765.x Paracetamol Poisoning, Victorian Poisons Information Centre, 2021 [internet publication].