Staggered paracetamol overdose and transplant thresholds

Risk and nomogram. This is repeated supratherapeutic ingestion with an uncertain exact last-dose time, not an acute immediate-release ingestion with a known time. The nomogram does not apply. ALT above 1000 U/L requires at least a full 20-hour course.^[4]

NAC plan. Use the ANZ two-bag regimen: 200 mg/kg over four hours then 100 mg/kg over 16 hours, continuing at the second-infusion rate if needed. Repeat pathology at least every 12 hours during prolonged treatment. Stop only when ALT or AST is decreasing, INR is below 2.0 and the patient is clinically well.^[4]

Transplant referral. Poor prognostic indicators in acetaminophen-induced fulminant hepatic failure are arterial pH below 7.30, prothrombin time above 100 seconds and creatinine above 300 micromol/L.^[9] The post-resuscitation lactate of 3.9 exceeds the 3.0 mmol/L threshold that had sensitivity 76 per cent and specificity 97 per cent for death without transplantation; adding post-resuscitation lactate to King's College criteria increased sensitivity from 76 to 91 per cent.^[5]