Usual Adult Dose for Acetaminophen Overdose

Injectable:
The total dose is 300 mg/kg, given as 3 separate doses, administered over a total of 21 hrs.
Dose preparation is weight based:

5 to 20 kg:
Loading Dose: 150 mg/kg in 3 mL/kg diluent, infused over 1 hour
Second Dose: 50 mg/kg in 7 mL/kg diluent, infused over 4 hours
Third Dose: 100 mg/kg in 14 mL/kg diluent, infused over 16 hours

21 to 40 kg:
Loading Dose: 150 mg/kg in 100 mL diluent, infused over 1 hour
Second Dose: 50 mg/kg in 250 mL diluent, infused over 4 hours
Third Dose: 100 mg/kg in 500 mL diluent, infused over 16 hours

41 to 100 kg:
Loading Dose: 150 mg/kg in 200 mL diluent, infused over 1 hour
Second Dose: 50 mg/kg in 500 mL diluent, infused over 4 hours
Third Dose: 100 mg/kg in 1,000 mL diluent, infused over 16 hours

Over 100 kg:
Loading Dose: 15,000 mg in 200 mL diluent, infused over 1 hour
Second Dose: 5,000 mg in 500 mL diluent, infused over 4 hours
Third Dose: 10,000 mg in 1,000 mL diluent, infused over 16 hours

Compatible diluents: 5% Dextrose in Water, 0.45% Sodium Chloride Injection, and Sterile Water for Injection

Comments:

• Limited information is available regarding dosing patients weighing more than 100 kg; there are no specific studies.
• The critical ingestion to treatment interval is 0 to 8 hours for maximal protection against severe hepatic injury.
• Efficacy diminishes progressively after 8 hours.
• Initiating treatment 15 to 24 hours post-ingestion yields limited efficacy, but does not appear to worsen the patient's condition and it should not be withheld, as reported ingestion time may not be correct.
• Determine serum acetaminophen level at least 4 hours after ingestion of suspected overdose to determine the need for treatment with acetylcysteine.
• If patient presents after 4 hours post-ingestion, determine the serum acetaminophen level immediately.
• Administer within 8 hours from acetaminophen ingestion for maximal protection against hepatic injury for patients whose serum acetaminophen levels fall above the "possible" toxicity line on the Rumack-Matthew nomogram (line connecting 150 mcg/mL at 4 hours with 37.5 mcg/mL at 12 hours); the manufacturer product information should be consulted.
• Administer immediately if time of ingestion is unknown, or serum acetaminophen level is not available/cannot be interpreted/is not available within 8 hours of ingestion.
• Administer immediately if 24 hours or less have elapsed from the reported time of overdose, regardless of the ingested quantity reported.

Use: Antidote for Acute Ingestion or Repeated Supratherapeutic Ingestion (RSI) acetaminophen overdose, to prevent or lessen hepatic injury after ingestion of a potentially hepatotoxic quantity of acetaminophen.

----

Oral administration of 20% solution for inhalation:
Loading Dose: 140 mg/kg body weight, orally, once as a loading dose (see preparation instructions below)
Maintenance Dose: 70 mg/kg body weight, orally, 4 hours after the loading dose and every 4 hours for 17 total doses, unless repeated acetaminophen assays reveal nontoxic levels (see preparation instructions below)
Dose preparation is weight based:

100 to 109 kg/220 to 240 lb:
Loading dose: 15 g (75 mL) in 225 mL diluent; total volume: 300 mL
Maintenance Dose: 7.5 g (37 mL) in 113 mL diluent; total volume: 150 mL

90 to 99 kg/198 to 218 lb:
Loading dose: 14 g (70 mL) in 210 mL diluent; total volume: 280 mL
Maintenance Dose: 7 g (35 mL) in 105 mL diluent; total volume: 140 mL

80 to 89 kg/176 to 196 lb:
Loading dose: 13 g (65 mL) in 195 mL) in 210 mL diluent; total volume: 260 mL
Maintenance Dose: 6.5 g (33 mL) in 97 mL diluent; total volume: 130 mL

70 to 79 kg/154 to 174 lb:
Loading dose: 11 g (55 mL) in 165 mL) in 210 mL diluent; total volume: 220 mL
Maintenance Dose: 5.5 g (28 mL) in 82 mL diluent; total volume: 110 mL

60 to 69 kg/132 to 152 lb:
Loading dose: 10 g (50 mL) in 150 mL) in 210 mL diluent; total volume: 200 mL
Maintenance Dose: 5 g (25 mL) in 75 mL diluent; total volume: 100 mL

50 to 59 kg/110 to 130 lb:
Loading dose: 8 g (40 mL) in 120 mL) in 210 mL diluent; total volume: 160 mL
Maintenance Dose: 4 g (20 mL) in 60 mL diluent; total volume: 80 mL

40 to 49 kg/88 to 108 lb:
Loading dose: 7 g (35 mL) in 105 mL) in 210 mL diluent; total volume: 140 mL
Maintenance Dose: 3.5 g (18 mL) in 52 mL diluent; total volume: 70 mL

30 to 39 kg/66 to 86 lb:
Loading dose: 6 g (30 mL) in 90 mL) in 210 mL diluent; total volume: 120 mL
Maintenance Dose: 3 g (15 mL) in 45 mL diluent; total volume: 60 mL

20 to 29 kg/44 to 64 lb:
Loading dose: 4 g (20 mL) in 60 mL) in 210 mL diluent; total volume: 80 mL
Maintenance Dose: 2 g (10 mL) in 30 mL diluent; total volume: 40 mL

Less than 20 kg (usually patients younger than 6 years), must calculate diluent volume:
Loading dose: 140 g/kg
Maintenance Dose: 70 g/kg

• Add 3 mL of diluent to each 1 mL (200 mg) of 20% acetylcysteine solution
• Do not decrease the proportion of diluent.

Diluents: Dilute in diet cola or other diet soft drink; if giving via g-tube or Miller-Abbott tube, may dilute with water.

Comments:

• Administer immediately if 24 hours or less from ingestion of an overdose, regardless of the quantity of acetaminophen reported to have been ingested. Do not await acetaminophen assay results before initiating treatment.

The following procedures are recommended:

• Empty stomach promptly by lavage or inducing emesis with syrup of ipecac.
• Activated charcoal may be indicated for a mixed drug overdose, but if used, lavage before administering acetylcysteine. Activated charcoal adsorbs acetylcysteine in vitro and may reduce its effectiveness.
• Draw blood for predetoxification acetaminophen plasma assay and baseline SGOT, SGPT, bilirubin, prothrombin time, creatinine, BUN, blood sugar and electrolytes.
• Administer the loading dose of acetylcysteine.
• Determine subsequent action based on predetoxification plasma acetaminophen information. Choose ONE of the following courses of therapy:

A. Predetoxification plasma acetaminophen level is clearly in the toxic range or cannot be obtained:
Administer first maintenance dose (70 g/kg acetylcysteine) 4 hours after the loading dose; repeat at 4-hour intervals for a total of 17 doses. Monitor hepatic and renal function and electrolytes throughout the detoxification process.

B. Predetoxification acetaminophen level is clearly in the non-toxic range (beneath the dashed line on the nomogram) and you know that overdose occurred at least 4 hours before the level was taken:
Discontinue acetylcysteine.

C. Predetoxification acetaminophen level was in the non-toxic range, but time of ingestion was unknown or less than 4 hours:
Obtain a second plasma level to decide if the full 17 dose treatment is necessary (acetaminophen peak may not be achieved before 4 hours post-ingestion, so the assay level may not be a peak value).

• If the patient vomits an oral dose within 1 hour of administration, repeat that dose.
• If the patient is persistently unable to retain oral acetylcysteine, the antidote may be administered by duodenal intubation.

Use: As an antidote to prevent or lessen hepatic injury which may occur following the ingestion of a potentially hepatotoxic quantity of acetaminophen.

Usual Adult Dose for Diagnostic Bronchograms

Nebulized into a face mask, mouth piece, or tracheostomy:
Recommended dosage: 3 to 5 mL of 20% solution, or 6 to 10 mL of 10% solution, 3 to 4 times a day
Dosage range: 1 to 10 mL of 20% solution, or 2 to 20 mL of 10% solution, every 2 to 6 hours

Nebulization tent, Croupette:
Recommended dose: The volume of 10% or 20% solution that will maintain a very heavy mist in the tent or Croupette for the desired period.

• This requires very large solution volumes, as much as 300 mL in a single treatment period.
• Intermittent or continuous prolonged administration periods, including overnight, may be desirable.
• Nebulization into a tent or Croupette must be individualized.
• Take into account the available equipment.

Direct Instillation:
Dose range: 1 to 2 mL of 10% to 20% solution, as often as every hour.

• Routine tracheostomy care: 1 to 2 mL of 10% to 20% solution, every 1 to 4 hours, instilled into the tracheostomy
• Percutaneous intratracheal catheter: 1 to 2 mL of 20% solution, or 2 to 4 mL of 10% solution, every 1 to 4 hours, via a syringe attached to the catheter
• Direct pulmonary installation: 2 to 5 mL of 20% solution
• Introduce directly into a particular segment of the bronchopulmonary tree by inserting (under local anesthesia and direct vision) a small plastic catheter into the trachea; instill using a syringe connected to the catheter.

Diagnostic Bronchograms:
Recommended dosing: 1 to 2 mL of the 20% solution, or 2 to 4 mL of the 10% solution, by nebulization or by instillation intratracheally, two or three times prior to the procedure.

Comments:

• The 20% solution may be diluted to a lesser concentration with either Sodium Chloride Injection, Sodium Chloride Inhalation Solution, Sterile Water for Injection, or Sterile Water for Inhalation.
• The 10% solution may be used undiluted.
• Use compressed tank gas (air) or an air compressor to provide pressure for nebulizing the solution.
• Oxygen may also be used but should be used with the usual precautions in patients with severe respiratory disease and CO2 retention.

Use: Adjuvant therapy for abnormal, viscid, or inspissated mucous secretions, such as in:
Chronic bronchopulmonary disease (chronic emphysema or asthmatic bronchitis, emphysema with bronchitis, tuberculosis, bronchiectasis, or primary pulmonary amyloidosis)
Acute bronchopulmonary disease (pneumonia, bronchitis, tracheobronchitis)
Pulmonary complications of cystic fibrosis
Tracheostomy care
Pulmonary complications associated with surgery
Use during anesthesia
Post-traumatic chest conditions
Atelectasis due to mucous obstruction
Diagnostic bronchial studies (bronchograms, bronchospirometry, and bronchial wedge catheterization)

Usual Adult Dose for Mucolytic

Nebulized into a face mask, mouth piece, or tracheostomy:
Recommended dosage: 3 to 5 mL of 20% solution, or 6 to 10 mL of 10% solution, 3 to 4 times a day
Dosage range: 1 to 10 mL of 20% solution, or 2 to 20 mL of 10% solution, every 2 to 6 hours

Nebulization tent, Croupette:
Recommended dose: The volume of 10% or 20% solution that will maintain a very heavy mist in the tent or Croupette for the desired period.

• This requires very large solution volumes, as much as 300 mL in a single treatment period.
• Intermittent or continuous prolonged administration periods, including overnight, may be desirable.
• Nebulization into a tent or Croupette must be individualized.
• Take into account the available equipment.

Direct Instillation:
Dose range: 1 to 2 mL of 10% to 20% solution, as often as every hour.

• Routine tracheostomy care: 1 to 2 mL of 10% to 20% solution, every 1 to 4 hours, instilled into the tracheostomy
• Percutaneous intratracheal catheter: 1 to 2 mL of 20% solution, or 2 to 4 mL of 10% solution, every 1 to 4 hours, via a syringe attached to the catheter
• Direct pulmonary installation: 2 to 5 mL of 20% solution
• Introduce directly into a particular segment of the bronchopulmonary tree by inserting (under local anesthesia and direct vision) a small plastic catheter into the trachea; instill using a syringe connected to the catheter.

Diagnostic Bronchograms:
Recommended dosing: 1 to 2 mL of the 20% solution, or 2 to 4 mL of the 10% solution, by nebulization or by instillation intratracheally, two or three times prior to the procedure.

Comments:

• The 20% solution may be diluted to a lesser concentration with either Sodium Chloride Injection, Sodium Chloride Inhalation Solution, Sterile Water for Injection, or Sterile Water for Inhalation.
• The 10% solution may be used undiluted.
• Use compressed tank gas (air) or an air compressor to provide pressure for nebulizing the solution.
• Oxygen may also be used but should be used with the usual precautions in patients with severe respiratory disease and CO2 retention.

Use: Adjuvant therapy for abnormal, viscid, or inspissated mucous secretions, such as in:
Chronic bronchopulmonary disease (chronic emphysema or asthmatic bronchitis, emphysema with bronchitis, tuberculosis, bronchiectasis, or primary pulmonary amyloidosis)
Acute bronchopulmonary disease (pneumonia, bronchitis, tracheobronchitis)
Pulmonary complications of cystic fibrosis
Tracheostomy care
Pulmonary complications associated with surgery
Use during anesthesia
Post-traumatic chest conditions
Atelectasis due to mucous obstruction
Diagnostic bronchial studies (bronchograms, bronchospirometry, and bronchial wedge catheterization)

Usual Pediatric Dose for Acetaminophen Overdose

Injectable:
The total dose is 300 mg/kg, given as 3 separate doses, administered over a total of 21 hrs.
Dose preparation is weight based:

5 to 20 kg:
Loading Dose: 150 mg/kg in 3 mL/kg diluent, infused over 1 hour
Second Dose: 50 mg/kg in 7 mL/kg diluent, infused over 4 hours
Third Dose: 100 mg/kg in 14 mL/kg diluent, infused over 16 hours

21 to 40 kg:
Loading Dose: 150 mg/kg in 100 mL diluent, infused over 1 hour
Second Dose: 50 mg/kg in 250 mL diluent, infused over 4 hours
Third Dose: 100 mg/kg in 500 mL diluent, infused over 16 hours

41 to 100 kg:
Loading Dose: 150 mg/kg in 200 mL diluent, infused over 1 hour
Second Dose: 50 mg/kg in 500 mL diluent, infused over 4 hours
Third Dose: 100 mg/kg in 1,000 mL diluent, infused over 16 hours

Over 100 kg:
Loading Dose: 15,000 mg in 200 mL diluent, infused over 1 hour
Second Dose: 5,000 mg in 500 mL diluent, infused over 4 hours
Third Dose: 10,000 mg in 1,000 mL diluent, infused over 16 hours

Compatible diluents: 5% Dextrose in Water, 0.45% Sodium Chloride Injection, and Sterile Water for Injection

Comments:

• Limited information is available regarding dosing patients weighing more than 100 kg; there are no specific studies.
• The critical ingestion to treatment interval is 0 to 8 hours for maximal protection against severe hepatic injury.
• Efficacy diminishes progressively after 8 hours.
• Initiating treatment 15 to 24 hours post-ingestion yields limited efficacy, but does not appear to worsen the patient's condition and it should not be withheld, as reported ingestion time may not be correct.
• Determine serum acetaminophen level at least 4 hours after ingestion of suspected overdose to determine the need for treatment with acetylcysteine.
• If patient presents after 4 hours post-ingestion, determine the serum acetaminophen level immediately.
• Administer within 8 hours from acetaminophen ingestion for maximal protection against hepatic injury for patients whose serum acetaminophen levels fall above the "possible" toxicity line on the Rumack-Matthew nomogram (line connecting 150 mcg/mL at 4 hours with 37.5 mcg/mL at 12 hours); the manufacturer product information should be consulted.
• Administer immediately if time of ingestion is unknown, or serum acetaminophen level is not available/cannot be interpreted/is not available within 8 hours of ingestion.
• Administer immediately if 24 hours or less have elapsed from the reported time of overdose, regardless of the ingested quantity reported.

Use: Antidote for Acute Ingestion or Repeated Supratherapeutic Ingestion (RSI) acetaminophen overdose, to prevent or lessen hepatic injury after ingestion of a potentially hepatotoxic quantity of acetaminophen.

----

Oral administration of 20% solution for inhalation:
Loading Dose: 140 mg/kg body weight, orally, once as a loading dose (see preparation instructions below)
Maintenance Dose: 70 mg/kg body weight, orally, 4 hours after the loading dose and every 4 hours for 17 total doses, unless repeated acetaminophen assays reveal nontoxic levels (see preparation instructions below)
Dose preparation is weight based:

100 to 109 kg/220 to 240 lb:
Loading dose: 15 g (75 mL) in 225 mL diluent; total volume: 300 mL
Maintenance Dose: 7.5 g (37 mL) in 113 mL diluent; total volume: 150 mL

90 to 99 kg/198 to 218 lb:
Loading dose: 14 g (70 mL) in 210 mL diluent; total volume: 280 mL
Maintenance Dose: 7 g (35 mL) in 105 mL diluent; total volume: 140 mL

80 to 89 kg/176 to 196 lb:
Loading dose: 13 g (65 mL) in 195 mL) in 210 mL diluent; total volume: 260 mL
Maintenance Dose: 6.5 g (33 mL) in 97 mL diluent; total volume: 130 mL

70 to 79 kg/154 to 174 lb:
Loading dose: 11 g (55 mL) in 165 mL) in 210 mL diluent; total volume: 220 mL
Maintenance Dose: 5.5 g (28 mL) in 82 mL diluent; total volume: 110 mL

60 to 69 kg/132 to 152 lb:
Loading dose: 10 g (50 mL) in 150 mL) in 210 mL diluent; total volume: 200 mL
Maintenance Dose: 5 g (25 mL) in 75 mL diluent; total volume: 100 mL

50 to 59 kg/110 to 130 lb:
Loading dose: 8 g (40 mL) in 120 mL) in 210 mL diluent; total volume: 160 mL
Maintenance Dose: 4 g (20 mL) in 60 mL diluent; total volume: 80 mL

40 to 49 kg/88 to 108 lb:
Loading dose: 7 g (35 mL) in 105 mL) in 210 mL diluent; total volume: 140 mL
Maintenance Dose: 3.5 g (18 mL) in 52 mL diluent; total volume: 70 mL

30 to 39 kg/66 to 86 lb:
Loading dose: 6 g (30 mL) in 90 mL) in 210 mL diluent; total volume: 120 mL
Maintenance Dose: 3 g (15 mL) in 45 mL diluent; total volume: 60 mL

20 to 29 kg/44 to 64 lb:
Loading dose: 4 g (20 mL) in 60 mL) in 210 mL diluent; total volume: 80 mL
Maintenance Dose: 2 g (10 mL) in 30 mL diluent; total volume: 40 mL

Less than 20 kg (usually patients younger than 6 years), must calculate diluent volume:
Loading dose: 140 g/kg
Maintenance Dose: 70 g/kg

• Add 3 mL of diluent to each 1 mL (200 mg) of 20% acetylcysteine solution
• Do not decrease the proportion of diluent.

Diluents: Dilute in diet cola or other diet soft drink; if giving via g-tube or Miller-Abbott tube, may dilute with water.

Comments:

• Administer immediately if 24 hours or less from ingestion of an overdose, regardless of the quantity of acetaminophen reported to have been ingested. Do not await acetaminophen assay results before initiating treatment.

The following procedures are recommended:

• Empty stomach promptly by lavage or inducing emesis with syrup of ipecac.
• Activated charcoal may be indicated for a mixed drug overdose, but if used, lavage before administering acetylcysteine. Activated charcoal adsorbs acetylcysteine in vitro and may reduce its effectiveness.
• Draw blood for predetoxification acetaminophen plasma assay and baseline SGOT, SGPT, bilirubin, prothrombin time, creatinine, BUN, blood sugar and electrolytes.
• Administer the loading dose of acetylcysteine.
• Determine subsequent action based on predetoxification plasma acetaminophen information. Choose ONE of the following courses of therapy:

A. Predetoxification plasma acetaminophen level is clearly in the toxic range or cannot be obtained:
Administer first maintenance dose (70 g/kg acetylcysteine) 4 hours after the loading dose; repeat at 4-hour intervals for a total of 17 doses. Monitor hepatic and renal function and electrolytes throughout the detoxification process.

B. Predetoxification acetaminophen level is clearly in the non-toxic range (beneath the dashed line on the nomogram) and you know that overdose occurred at least 4 hours before the level was taken:
Discontinue acetylcysteine.

C. Predetoxification acetaminophen level was in the non-toxic range, but time of ingestion was unknown or less than 4 hours:
Obtain a second plasma level to decide if the full 17 dose treatment is necessary (acetaminophen peak may not be achieved before 4 hours post-ingestion, so the assay level may not be a peak value).

• If the patient vomits an oral dose within 1 hour of administration, repeat that dose.
• If the patient is persistently unable to retain oral acetylcysteine, the antidote may be administered by duodenal intubation.

Use: As an antidote to prevent or lessen hepatic injury which may occur following the ingestion of a potentially hepatotoxic quantity of acetaminophen.

Usual Pediatric Dose for Diagnostic Bronchograms

Nebulized into a face mask, mouth piece, or tracheostomy:
Recommended dosage: 3 to 5 mL of 20% solution, or 6 to 10 mL of 10% solution, 3 to 4 times a day
Dosage range: 1 to 10 mL of 20% solution, or 2 to 20 mL of 10% solution, every 2 to 6 hours

Nebulization tent, Croupette:
Recommended dose: The volume of 10% or 20% solution that will maintain a very heavy mist in the tent or Croupette for the desired period.

• This requires very large solution volumes, as much as 300 mL in a single treatment period.
• Intermittent or continuous prolonged administration periods, including overnight, may be desirable.
• Nebulization into a tent or Croupette must be individualized.
• Take into account the available equipment.

Direct Instillation:
Dose range: 1 to 2 mL of 10% to 20% solution, as often as every hour.

• Routine tracheostomy care: 1 to 2 mL of 10% to 20% solution, every 1 to 4 hours, instilled into the tracheostomy
• Percutaneous intratracheal catheter: 1 to 2 mL of 20% solution, or 2 to 4 mL of 10% solution, every 1 to 4 hours, via a syringe attached to the catheter
• Direct pulmonary installation: 2 to 5 mL of 20% solution
• Introduce directly into a particular segment of the bronchopulmonary tree by inserting (under local anesthesia and direct vision) a small plastic catheter into the trachea; instill using a syringe connected to the catheter.

Diagnostic Bronchograms:
Recommended dosing: 1 to 2 mL of the 20% solution, or 2 to 4 mL of the 10% solution, by nebulization or by instillation intratracheally, two or three times prior to the procedure.

Comments:

• The 20% solution may be diluted to a lesser concentration with either Sodium Chloride Injection, Sodium Chloride Inhalation Solution, Sterile Water for Injection, or Sterile Water for Inhalation.
• The 10% solution may be used undiluted.
• Use compressed tank gas (air) or an air compressor to provide pressure for nebulizing the solution.
• Oxygen may also be used but should be used with the usual precautions in patients with severe respiratory disease and CO2 retention.

Use: Adjuvant therapy for abnormal, viscid, or inspissated mucous secretions, such as in:
Chronic bronchopulmonary disease (chronic emphysema or asthmatic bronchitis, emphysema with bronchitis, tuberculosis, bronchiectasis, or primary pulmonary amyloidosis)
Acute bronchopulmonary disease (pneumonia, bronchitis, tracheobronchitis)
Pulmonary complications of cystic fibrosis
Tracheostomy care
Pulmonary complications associated with surgery
Use during anesthesia
Post-traumatic chest conditions
Atelectasis due to mucous obstruction
Diagnostic bronchial studies (bronchograms, bronchospirometry, and bronchial wedge catheterization)

Usual Pediatric Dose for Mucolytic

Nebulized into a face mask, mouth piece, or tracheostomy:
Recommended dosage: 3 to 5 mL of 20% solution, or 6 to 10 mL of 10% solution, 3 to 4 times a day
Dosage range: 1 to 10 mL of 20% solution, or 2 to 20 mL of 10% solution, every 2 to 6 hours

Nebulization tent, Croupette:
Recommended dose: The volume of 10% or 20% solution that will maintain a very heavy mist in the tent or Croupette for the desired period.

• This requires very large solution volumes, as much as 300 mL in a single treatment period.
• Intermittent or continuous prolonged administration periods, including overnight, may be desirable.
• Nebulization into a tent or Croupette must be individualized.
• Take into account the available equipment.

Direct Instillation:
Dose range: 1 to 2 mL of 10% to 20% solution, as often as every hour.

• Routine tracheostomy care: 1 to 2 mL of 10% to 20% solution, every 1 to 4 hours, instilled into the tracheostomy
• Percutaneous intratracheal catheter: 1 to 2 mL of 20% solution, or 2 to 4 mL of 10% solution, every 1 to 4 hours, via a syringe attached to the catheter
• Direct pulmonary installation: 2 to 5 mL of 20% solution
• Introduce directly into a particular segment of the bronchopulmonary tree by inserting (under local anesthesia and direct vision) a small plastic catheter into the trachea; instill using a syringe connected to the catheter.

Diagnostic Bronchograms:
Recommended dosing: 1 to 2 mL of the 20% solution, or 2 to 4 mL of the 10% solution, by nebulization or by instillation intratracheally, two or three times prior to the procedure.

Comments:

• The 20% solution may be diluted to a lesser concentration with either Sodium Chloride Injection, Sodium Chloride Inhalation Solution, Sterile Water for Injection, or Sterile Water for Inhalation.
• The 10% solution may be used undiluted.
• Use compressed tank gas (air) or an air compressor to provide pressure for nebulizing the solution.
• Oxygen may also be used but should be used with the usual precautions in patients with severe respiratory disease and CO2 retention.

Use: Adjuvant therapy for abnormal, viscid, or inspissated mucous secretions, such as in:
Chronic bronchopulmonary disease (chronic emphysema or asthmatic bronchitis, emphysema with bronchitis, tuberculosis, bronchiectasis, or primary pulmonary amyloidosis)
Acute bronchopulmonary disease (pneumonia, bronchitis, tracheobronchitis)
Pulmonary complications of cystic fibrosis
Tracheostomy care
Pulmonary complications associated with surgery
Use during anesthesia
Post-traumatic chest conditions
Atelectasis due to mucous obstruction
Diagnostic bronchial studies (bronchograms, bronchospirometry, and bronchial wedge catheterization)

Renal Dose Adjustments

Data not available

Liver Dose Adjustments

Data are not available to determine if dose adjustment is required. Published literature does not indicate a need for dose reduction.

Dose Adjustments

ACETAMINOPHEN OVERDOSE:

Volume Adjustment: Patients less than 40 kg and Requiring Fluid Restriction

• Adjust the total volume administered.
• Reduce volume of diluent as clinically needed to avoid fluid overload, which can lead to hyponatremia, seizure and death.
• The injection is hyperosmolar (2600 mOsmol/L); use caution.
• As the diluent volume decreases the solution hyperosmolarity increases. For example, if the:

Drug concentration is: Osmolarity in: 0.45% Sodium Chloride (1/2NS) is; 5% Dextrose (D5W) is; Sterile Water for Injection (SWFI) is:

7 mg/mL: 245 mOsmol/L in 1/2NS; 343 mOsmol/L in D5W; 91 mOsmol/L in SWFI
24 mg/mL: 466 mOsmol/L in 1/2NS; 564 mOsmol/L in D5W; 312 mOsmol/L in SWFI

• Adjust osmolarity to a physiologically safe level, (generally not less than 150mOsmol/L in children).

Continued Therapy Beyond 21 Hours:

• There is no clinical trial data supporting use beyond 21 hours.
• Literature supports continued infusion in some rare instances: suspected massive overdose, or concomitant ingestion of other substances.
• In preexisting liver disease, acetaminophen absorption and/or half-life may be prolonged: consider the need for continued infusion beyond 21 hours.
• Check acetaminophen levels, ALT/AST, and INR before the end of the 21-hour infusion.
• If acetaminophen levels are still detectable, or ALT/AST are still increasing, or INR remains elevated: continue the infusion, and have the treating physician contact a US regional poison center at 1-800-222-1222, or a special health professional assistance line for acetaminophen overdose at 1-800-525-6115, for assistance with dosing recommendations.

Dialysis

Data not available

Other Comments

Administration advice:
Acetaminophen Overdose:

• For specific treatment information/clinical management, contact your regional poison center at 1-800-222-1222, or alternatively, a special health professional assistance line for acetaminophen overdose at 1-800-525-6115.
• The manufacturer product information should be consulted for interpretation of acetaminophen assays.

Administration of Aerosol:

• To prevent acetylcysteine concentrating in the solution after prolonged nebulization, dilute with an equal volume of sterile water for injection, when three-quarters of the initial volume has been nebulized.
• The manufacturer product information should be consulted.

Storage requirements:

• Injection: Single dose vial, preservative-free, discard unused portion.
• If vial was previously opened, do not use for intravenous administration.
• Diluted solution for injection is stable for 24 hours at controlled room temperature.
• Inhalation: If only a portion of the solution in a vial is used, refrigerate the remainder and use within 96 hours.

Reconstitution/preparation techniques:

• Preparation for Oral Administration: Dilute the 20% solution with diet cola or other diet soft drinks, to a final concentration of 5% (the manufacturer product information should be consulted). If administered via gastric tube or Miller-Abbott tube, may use water as the diluent.
• The oral dilutions should be freshly prepared and utilized within one hour; remaining undiluted solutions in opened vials can be stored in the refrigerator up to 96 hours.
• Acetylcysteine for inhalation does not contain an antimicrobial agent, and care must be taken to minimize contamination of the sterile solution.

General:

• The color of the Injection may turn from essentially colorless to a slight pink or purple once the stopper is punctured. The color change does not affect the quality of the product.
• Clean nebulizing equipment immediately after use; residues may clog smaller orifices or corrode metal parts.

Monitoring (acetaminophen overdose):

• Determine aspartate aminotransferase (AST, SGOT), alanine aminotransferase (ALT, SGPT), bilirubin, prothrombin time, creatinine, blood urea nitrogen (BUN), blood glucose, and electrolytes to monitor hepatic and renal function, and electrolyte and fluid balance.
• Repeat SGOT, SGPT, bilirubin, prothrombin time, creatinine, BUN, blood sugar and electrolytes daily if the acetaminophen plasma level is in the potentially toxic range.

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