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1 Assistant Professor and Research Director, Division of Emergency Medicine,
Campus Box 8072, 660 South Euclid Avenue, Washington University, St. Louis,
Missouri 63110-1093, fax 314/362-0478,
mullinsm{at}wusm.wustl.edu
2 Assistant Professor, Division of Emergency Medicine, Washington
University
3 Assistant Professor, Division of Emergency Medicine, Washington
University
4 Clinical Pharmacist, Department of Pharmacy, Barnes-Jewish Hospital, St.
Louis, Missouri
Published Online, November 25, 2008. www.theannals.com, DOI 10.1345/aph.1K685a
Prior to the approval of Acetadote, we had several years of experience in administering filtered acetylcysteine inhalation solution intravenously off-label. Our approach then, which has continued with our use of Acetadote, was to utilize a simpler 1-bag method. The infusion is prepared by adding 30 g of acetylcysteine 20% solution (150 mL) to 850 mL of dextrose 5% in water (D5W; volume-adjusted 1000-mL bag), which results in a final concentration of 30 mg/mL. Acetylcysteine remains stable, sterile, and pyrogen-free for at least 60 hours after addition to the intravenous bag.3
This 1-bag method is even simpler than the 2-bag method suggested by Ferner et al.4 and offers several advantages. With 1 bag, there is no delay in the arrival of the second or third bags to the patient's bedside, which eliminates the most frequent error recorded by Hayes et al.1 The ordering and preparation of the infusion is simple, standardized, and easily remembered by pharmacists and physicians. This method enhances compliance with the standardized intravenous drip concentration mandate and allows for use of preprogrammed intravenous concentrations in smart pump data libraries. The nursing staff need to make only 2 scheduled changes in the infusion. The infusion started in the emergency department accompanies the patient to the ward.
A loading dose of 150 mg/kg/h for 1 hour followed by 12.5 mg/kg/h for 4 hours and then 6.25 mg/kg/h for 16 hours results in the same total dose (300 mg/kg) as the 3-bag method. In our practice, we use a dosage of 14 mg/kg/h for 20 hours after the loading dose of 150 mg/kg and omit the decrement to the terminal infusion rate. The total dose is 430 mg/kg over 21 hours. Eliminating the second change in infusion rate further reduces nursing workload and dosing errors. Both the 1-bag method and our single infusion rate are off-label and not approved by the Food and Drug Administration or the manufacturer.
We advocate the 1-bag method with a single infusion rate after the loading dose to reduce dosing errors and to improve patient safety.
References
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