Document Type : Case Report


1 Assistant Professor, Department of Pediatrics, Lorestan University of Medical Sciences, Khorramabad, Iran

2 Department of Pediatrics, Lorestan University of Medical Sciences, Khorramabad, Iran

3 Medical Student, Student Research Committee, Lorestan University of Medical Sciences, Khorramabad, Iran



N-acetylcysteine (NAC) is a drug  used  widely and effectively in oral  and  ‎intravenous  forms  as  a  specific  antidote  for acetaminophen poisoning.  In children ‎considering the toxic dose of acetaminophen ingested by the patient and the body weight, the ‎physician prescribes a specific dose of NAC. There is always a risk of  iatrogenic overdose of  ‎NAC  which can cause different mild to severe temporary or permanent  side effects, some of ‎which can be life threatening. Here we report a rare case of iatrogenic NAC overdose following ‎an error in calculation of the prescribed dose.‎The patient was a 2.5 years old boy that was brought to emergency room with overdose ‎of acetaminophen syrup. The Physician prescribed 2 grams of intravenous NAC for him, but ‎because of the miscalculation of the volume of the drug, the nurse infused about 20 grams of ‎NAC (10 times the prescribed dose) to the patient. Immediately the patient became drowsy and ‎developed decreased level of consciousness, stupor, repetitive intractable focal and generalized ‎convulsions, decrease visual acuity and had prolonged hospitalization in intensive care unit and ‎pediatric neurologic wards and perhaps will have permanent subtle intellectual and neurologic ‎sequela. Considering the possible errors in the prescription and administration of some ‎critical and less commonly used drugs especially those which have several different formulary ‎and also considering their possible serious and life threatening side effects, it is recommended ‎that the dose and volume of such medications be calculated meticulously by at least two trained ‎persons. Also it is important to carry out the administration phases and check the patient’s ‎symptoms more attentively and cautiously. ‎


Yang, X., Salminen, W., Shi, Q., Greenhaw, J., Gill, P., Bhattacharyya, S., et al. 2015. Toxicology and Applied Pharmacology. 284, 180-187.
Mahmudi, Gh., Anbari, Kh., Obeidavi, Z., 2013. Prevalence of clinical manifestations of poisoning in children admitted to hospitals of Khorramabad in 2011. Iranian Journal of Toxicology, 7 (22). 
Prescott, L.F., Illingworth, R.N., Critchley, J.A., Stewart, M.J., Adam, R.D., Proudfoot, A.T., 1977. Treatment of paracetamol (acetaminophen) poisoning with N-acetylcysteine. Lancet, 2, 432-434.
Ferner, R.E., Dear, J.W., Bateman, D.N., 2011. Management of paracetamol poisoning. BMJ, 342, d2218.
Heard, K.J., 2008. Acetylcysteine for acetaminophen poisoning. N. Engl. J. Med., 359, 285-292.
Bateman, D.N., Carroll, R., Pettie, J., Yamamoto, T., Elamin, M., Peart, L., Dow, M., Coyle, J., Cranfield, KR., Hook, C., Sandilands, EA., Veiraiah, A., Webb, D., Gray, A., Dargan, PI., Wood, DM., Thomas, SH., Dear, JW., Eddleston, M., 2014. Effect of the UK’s revised paracetamol poisoning management guidelines on admissions, adverse reactions and costs of treatment. Br. J. Clin. Pharmacol., 78(3), 610-618.
Whyte, I.M., Francis, B., Dawson, A.H., 2007. Safety and efficacy of intravenous N-acetylcysteine for acetaminophen overdose: analysis of the Hunter Area Toxicology Service (HATS) database. Curr. Med. Res. Opin., 23, 2359-68.
Lynch, R.M., Robertson, R., 2004. Anaphylactoid reactions to intravenous N-acetylcysteine: a prospective case controlled study. Accid. Emerg. Nurs., 12, 10-5.
Waring, W.S., Pettie, J.M., Dow, M.A., Bateman, D.N., 2006. Paracetamol appears to protect against N-acetylcysteine-induced anaphylactoid reactions. Clin. Toxicol., 44, 441-2.
Pakravan, N., Waring, W.S., Bateman, D.N., 2008. Risk factors and mechanisms of anaphylactoid reactions to acetylcysteine in acetaminophen overdose. Clin. Toxicol., 46, 697-702.
Schmidt, L., 2013. Identification of patients at risk of anaphylactoid reactions to N- Acetylcysteine in the treatment of paracetamol overdos. Clin. Toxicol., 51, 467-72.
Jalali, N., Kariman, N., Snaei zadeh, H., 2000. Evaluation of NAC treatment side effect in acetaminophen poisoning. Journal of Shahid Sadoughi University of Medical Sciences, 9(3), 25-28.
Diallo, A., Eliassou, M., Djadou, K., Potchoo, Y., Creppy, E.E., 2016. Accidental Acute Poisoning of two Children by Paracetamol-Codeine (1000 Mg/60 Mg) Association – A Case Report. Open J. Clin. Toxicol., 1(1), 001-003.
Manthripragada, A.D., Zhou, E.H., Budnitz, D.S., Lovegrove, M.C., Willy, M.E., 2011. Characterization of acetaminophen overdose-related emergency department visits and hospitalizations in the United States. Pharmacoepidemiol. Drug. Saf., 20(8), 819-826.
Green, J., Heard, K., Reynolds, K., Albert, D., 2013. Oral and Intravenous Acetylcysteine for Treatment of Acetaminophen Toxicity: A Systematic Review and Meta-analysis. Western Journal of Emergency Medicine, 14(3), 218-226.
Bateman, D.N., Dear, J.W., Thanacoody, H.K., Thomas, H.L., Eddleston, M., Sandilands, E.A., Coyle, J., Cooper, J.G., Rodriguez, A., Butcher, I., Lewis, S.C., Vliegenthart, A.D., Veiraiah, A., Webb, D.J., Gray, A., 2014. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomized controlled trial. Lancet, 383, 697-704.
Mowry, J.B., Spyker, D.A., Cantilena, L.R Jr., McMillan, N., Ford, M., 2014. 2013 Annual Report of the American Association of Poison Control Centers’ National poison data system (NPDS): 31st annual report. Clin. Toxicol. (Phila)., 52: 1032-1283.
Duffull, S.B., Isbister, G.K., 2013. Predicting the requirement for N-acetylcysteine in paracetamol poisoning from reported dose. Clin. Toxicol. (Phila)., 51, 772-776.
Buckley, N.A., Whyte, I.M., Dawson, A.H., 2015. A prospective cohort study of trends in self-poisoning, Newcastle, Australia, 1987-2012: plus ca change, plus c’est la meme chose. Med. J. Aust., 202, 438-442.
Prescott, L.F., Roscoe, P., Wright, N., Brown, S.S., 1971. Plasma-paracetamol half-life and hepatic necrosis in patients with paracetamol overdosage. Lancet, 1(7698), 519-22.
Isbistera, G., Downesa, M., Mcnamarab, K., Berlinga, I., Whytea, I., Pagea, C., 2015. A prospective observational study of a novel 2-phase infusion protocol for the administration of acetylcysteine in paracetamol poisoning. Clinical toxicology, 54(2), 120-126.
Wright, R.O., Perry, H.E., Woolf, A.D., Shannon, M.W., 1996. Hemolysis after acetaminophen overdose in a patient with glucose-6-phosphate dehydrogenase deficiency. J. Toxicol. Clin. Toxicol., 34, 731-734.
Heard, K., Schaeffer, T.H., 2011. Massive acetylcysteine overdose associated with cerebral edema and seizures. Clin. Toxicol., 49, 423-425.
Kante, M.Z., 2006. Comparison of oral and IV acetylcysteine in the treatment of acetaminophen poisoning. Am. J. Health Syst. Pharm., 63, 1821-1827.
Brok, J., Buckley, N., Gluud, C., 2006. Interventions for paracetamol (acetaminophen) overdose. Cochrane Database Syst. Rev., 2, CD003328.
Mahmoudi, Gh., Astaraki, P., Zafar Mohtashami, A., Ahadi, M., 2015. N-acetylcysteine overdose after acetaminophen poisoning. International Medical Case Reports Journal, 8, 65-69.
Slonim, A., LaFleur, B., Ahmed, W., Joseph, J., 2003. Hospital-Reported Medical Errors in Children. Pediatrics J., 111 (3), 617-621.
Zaboli, R., Abbaszadeh, A., Shahabinejad, M., 2015. Assessing the barriers of error reporting from perspective of nurses in Kerman hospitals. Medical Ethics Journal, 34 (9), 31-53.
Cramer, H., Pohlabeln, H., Habermann, M., 2013. Factors causing or influencing nursing errors as perceived by nurses: findings of a cross- sectional study in German nursing homes and hospitals. Journal of Public Health, 21(2):145-153.
Balas, M.G., Scott, L.D., Rogers, A.E., 2004. The prevalence and nature of errors and near errors reported by hospital staff nurses. Appl. Nurs. RES., 17(4), 224-33.
Wakefield, D.S., Wakefield, B.J., Uden-Holman, T., Borders, T., Blegen, M., Vaughn, T., 1999. Understanding why medication administration errors may not be reported. Am. J. Med. Qual., 14(2), 81-88.
Kalisch, B.J., Landstrom, G., Williams, R.A., 2009. Missed nursing care: errors of omission. Nursing Outlook, 57(1), 3-9.