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Paracetamol: Friend or Foe

Why can you never find an aspirin in the jungle? . Because those parrots eat

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Paracetamol: Friend or Foe

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    1. Paracetamol: Friend or Foe Annie Moulden (Paediatrician) Mike South (Paediatrician) Soula Zambetis (Senior Clinical Pharmacist) Royal Children’s Hospital, Melbourne

    2. Why can you never find an aspirin in the jungle?

    3. Paracetamol: Friend or Foe This Clinical Practice Review meeting was triggered by the recent report of a death of a child in NSW from paracetamol toxicity when the drug was given with therapeutic intent. A summary of the NSW Coroner findings can be read at www.rch.org.au/genmed/media/NSW-Coroner-on-paracetamol.pps

    4. Paracetamol quotes “I’ve been giving her Panadol but it isn’t working - I can’t get her temperature down” “Could you write him up for a routine paracetemol order just in case”

    5. Paracetamol - history

    6. RCH Usage Most commonly prescribed drug Monthly figures 630 x 100 mL (240 mg/5 mL) bottles 63 Litres / Month 230 x 24 pk, 500 mg tabs 5520 tabs / Month

    7. Paracetamol toxicity in therapeutic use Usually high therapeutic / supra-therapeutic doses Often over several days Often post-surgery Usually Co-morbidity Increasing number of reports in literature

    9. Paracetamol - actions analgesic antipyretic

    10. Paracetamol - analgesic

    11. Paracetamol - antipyretic

    12. Paracetamol - antipyretic

    13. Initiation of Fever

    14. Benefits of Fever Immunologic - these work better at higher temp helper T-lymphocyte proliferation enhanced T-lymphocyte cell killing enhanced interferon production and function Antimicrobial - these die at higher temp rhinovirus polio virus pneumococcus gonococcus syphilis treponeme

    15. Benefits of Fever - experimental Antipyretic treatment increased mortality from Aeromonas infection in desert iguanas. Untreated newborn mice infected with coxsackie virus had considerably lower mortality than those in which fever was suppressed. Adult volunteers experimentally infected with rhinovirus excreted the virus longer if treated with antipyretics. Children with chickenpox had a longer time to total crusting of lesions in paracetamol compared to placebo-treated subjects.

    16. Negative aspects of Fever Heat stroke - v. v. rare in children with fever of acute illness Febrile convulsions -2-5% of children ? Comfort / activity / appetite / mood

    17. So would antipyretics help? Heat stroke - v. v. rare in children with fever of acute illness Febrile convulsions -2-5% of children ? Comfort / activity / appetite / mood

    18. Paracetamol - antipyretic

    19. Paracetamol- How to avoid “accidental poisoning with therapeutic intent” Only use it when indicated Recognise potential benefits of fever, lack of harm and limited value of antipyresis. Treat pain and discomfort - not fever “Treat the child and not the thermometer” Educate parents. Avoid “Fever Phobia” Avoid “routine” PRN orders of paracetamol Take care in dosing & duration

    20. Avoid “routine” PRN orders

    21. Avoid “routine” PRN orders

    22. How to avoid “accidental poisoning with therapeutic intent” Usual dose 60mg/kg/day Max dose 90mg/kg/day (or 4g / day if > 45kg) Not for more than 2 days, especially if <2years Beware continued use at high doses Beware other drugs (esp alcohol, anticonvulsants) Beware use the sick child Beware poor renal or hepatic function Beware obesity (overdosing by weight, and associated liver dysfunction) Stop if child vomiting, drowsy, jaundiced

    23. Beware dose confusion RCH Paediatric Pharmacopoeia 15 mg/kg/dose 4-6 hrly. In an unsupervised, community setting, limit dosage to 60 mg/kg/24 hrs for up to 48 hrs. Up to 90 mg/kg/24 hrs can be used under medical supervision. Review after 48 hrs. Stat doses of 30 mg/kg may be used for night-time dosing RECTAL: 20-40 mg/kg as a once-off dose, rounded to appropriate suppository strength Peri-op analgesia - higher doses often used (sometimes up to 60mg/kg/dose)

    24. Confused yet?

    25. Paracetamol: Friend or Foe Soula Zambetis (Senior Clinical Pharmacist) Royal Children’s Hospital, Melbourne

    26. Practical Issues Transfers from... ward emergency theatre High rectal doses care when changing to oral NEW ORDER MUST BE WRITTEN New Drug chart use review date box

    27. Practical Issues Discharge prescriptions pharmacy department do not supply paracetamol or OTC items upon discharge problems arise when parents are told to give e.g. 5ml of paracetamol 120 mg/5 mL 240 mg/5 mL 100 mg/mL ( = 500 mg/5 mL)

    28. Paracetamol Awareness Poster “Paracetamol and your child” MIRC poster Paracetamol Dosage (for RCH inpatients) Keeping Tabs ? Future paracetamol discharge information sheet

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