Chiu Michael H, Jaworska Natalia, Li Nicholas L, Yarema Mark
Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, AB, Canada.
Department of Medicine, Division of Nephrology, Cumming School of Medicine, University of Calgary, AB, Canada.
Case Rep Crit Care. 2021 Jul 11;2021:6695967. doi: 10.1155/2021/6695967. eCollection 2021.
Acetaminophen overdose is one of the most common causes of acute hepatic failure in the developed world. There is strong evidence for N-acetylcysteine (NAC) as a safe and effective antidote for acetaminophen toxicity. However, there is less clarity in the management of massive overdoses (acute, single ingestions > 500 mg/kg with 4-hour equivalent concentrations ~6000 mol/L) which are often associated with metabolic acidosis and multiorgan dysfunction. In such ingestions, the role of adjuvant treatments such as fomepizole and extracorporeal removal is unclear. We present a case of a 20-year-old female presenting with an acute ingestion of over 120 grams (1764.7 mg/kg) and an acetaminophen concentration of 5880 mol/L who developed refractory shock, decreased level of consciousness, and metabolic acidosis requiring mechanical ventilation and vasopressor support. She was treated with gastric decontamination with activated charcoal, IV NAC, fomepizole, and hemodialysis. The patient had complete clearance of acetaminophen by 32 hours after presentation and normalization of her acid base and hemodynamic status without any organ failure. This case highlights the potential benefit of a triple strategy of NAC, fomepizole, and early hemodialysis in massive acetaminophen overdose, potentially sparing complications of prolonged intubation and ICU hospitalization.
对乙酰氨基酚过量是发达国家急性肝衰竭最常见的病因之一。有充分证据表明N - 乙酰半胱氨酸（NAC）是治疗对乙酰氨基酚中毒的一种安全有效的解毒剂。然而，对于大量服药过量（急性单次摄入>500mg/kg且4小时等效浓度~6000μmol/L）的处理尚不太明确，这种情况常伴有代谢性酸中毒和多器官功能障碍。在此类摄入情况下，诸如甲吡唑和体外清除等辅助治疗的作用尚不清楚。我们报告一例20岁女性病例，其急性摄入超过120克（1764.7mg/kg）对乙酰氨基酚，浓度为5880μmol/L，出现难治性休克、意识水平下降及代谢性酸中毒，需要机械通气和血管活性药物支持。她接受了活性炭洗胃、静脉注射NAC、甲吡唑及血液透析治疗。患者在就诊后32小时对乙酰氨基酚完全清除，酸碱及血流动力学状态恢复正常，未出现任何器官功能衰竭。该病例突出了NAC、甲吡唑及早期血液透析三联策略在大量对乙酰氨基酚过量中的潜在益处，可能避免长期插管及入住重症监护病房的并发症。
