ANALYTIC REVIEWS Management of Acetaminophen Toxicity in the Intensive Care Unit Edwin K. Kuffner, MD,* Kennon Heard, MD,* † and LCDR Gerald F. O’Malley, DO* Kuffner EK, Heard K, O’Malley GF. Management of Acetamino- Worldwide acetaminophen is one of the most phen Toxicity in the Intensive Care Unit. J Intensive Care Med widely prescribed and consumed analgesics and 1999;14:157–165. antipyretics. Each year in the United States aceta- Acetaminophen poisoning is the most common cause of minophen toxicity accounts for at least 100–150 medication overdose death in the United States. While most deaths, more than any other medication reported to patients can be safely managed outside the ICU, serious the American Association of Poison Control Centers toxicity can result in hepatic failure and death. N-acetylcys- Toxic Exposure Surveillance System [1]. Although teine has been shown to prevent liver injury when adminis- tered early and reduce mortality for patients with hepatic the majority of the patients who overdose on aceta- failure. The proposed mechanism of acetaminophen toxicity minophen do not develop life-threatening toxicity, and N-acetylcysteine therapy are discussed, as well as extra- hundreds of critically ill acetaminophen-toxic pa- hepatic toxicity of acetaminophen. Other topics that are tients require specialized care in ICUs annually. discussed include the interaction of ethanol consumption This article reviews the effects of acetaminophen and acetaminophen toxicity and recent advances in the man- agement of acetaminophen poisoning. poisoning that should be managed in an ICU, thera- peutic options for acetaminophen poisoning, and considerations for liver transplantation. We also dis- cuss several recent controversies in acetaminophen poisoning. Admission to an ICU Most patients requiring hospitalization following acetaminophen overdose do not need admission to an ICU. For example, patients with serum aceta- minophen levels above the recommended treat- ment line on the Rumack–Mathew nomogram, pa- tients with elevated hepatic transaminases and mild coagulopathy, and patients receiving intra- venous N-acetylcysteine (NAC) can be safely man- aged on a medical or pediatric ward. Patients who develop complications that require intensive care management usually do so gradually over the first few days postingestion. The subset of acetaminophen-toxic patients that should be admitted to an ICU include patients with hemodynamic instability, hepatic encephalopathy, fulminant hepatic failure, renal failure, and gastroin- testinal bleeding. Patients may present with mark- From the *Rocky Mountain Poison and Drug Center and † Depart- edly elevated serum acetaminophen concentrations ment of Surgery, University of Colorado Health Sciences Center, (> 800 g/ml), altered mental status, and acidosis Denver, CO. [2]. These patients require ICU care. Suicidal pa- Received Oct 8, 1998, and in revised form Jan 15, 1999. Accepted tients that cannot be properly monitored on either for publication Jan 20, 1999. a medical or pediatric ward may also warrant ICU Address correspondence to Dr Edwin Kuffner, Rocky Mountain admission. Finally, toxicity related to coingestants Poison and Drug Center, 8802 East 9th Ave., Denver, CO 80220–6800. may mandate ICU admission. Copyright  1999 Blackwell Science, Inc. 157