Unique Plan Description: Acetylcysteine (Acetadote) IV Protocol
Plan Selection Display: Acetylcysteine (Acetadote) IV Protocol
PlanType: Medical                                 
Version: 3          
Begin Effective Date: 2022-01-25 07:42:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-08-14 15:20:11
Available at all facilities: Yes

IV Treatment-Early (<8hr post ingest)
Laboratory
	ALT
		T;N, Stat, spec type = Blood
	AST
		T;N, Stat, spec type = Blood
	Bilirubin Total
		T;N, Stat, spec type = Blood
	INR - MH/WH/JE
		T;N, Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
	Acetaminophen Level
		T;N, Stat, spec type = Blood
		T;N+720, Timed, Q12H, spec type = Blood
	ALT
		T;N+720, Timed, Q12H, spec type = Blood
	AST
		T;N+720, Timed, Q12H, spec type = Blood
	Bilirubin Total
		T;N+720, Timed, Q12H, spec type = Blood
	INR - MH/WH/JE
		T;N+720, Timed, Q12H, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N+720, Q12H, Timed, spec type = Diagnostic Blood
		T;N+720, Q12H, Timed, spec type = Therapeutic Blood
	Basic Metabolic Panel
		T;N+1260, Routine, spec type = Blood
	Acetaminophen Level
		T;N+420, Timed, spec type = Blood
			Comment: Obtain level 7 hours after ingestion if APAP was co-ingested with an opioid or anticholinergic and the 4 hr APAP level is < 150mcg/ml; begin acetylcysteine protocol if level > 89mcg/ml, consider if 7 hr level will not be reported within 8 hours of ingestion.
IV Solutions
		Initiation less than 8 hours post acetaminophen ingestion-select the following 3 acetylcysteine IVPB orders:(NOTE)*
	acetylcysteine IVPB
		0.15 gm/kg, INT, IVPB, Once, 250 ml/hr, duration: 1 Dose(s)/Time(s)
			Comment: In D5W 250 mL.  Infuse over 60 minutes.  Bag 1 of 3. Max Dose 15g (dosing weight max= 100kg) 1. Monitor closely for bronchospasm and anaphylactoid reactions, especially during the loading dose and in those with risk factors for developing anaphylactoid reactions.  2. Stop the infusion in patients who develop anaphylactoid symptoms. Most reactions are mild and often resolve with temporary cessation of the IV NAC infusion. Reactions that are more than mild should be treated appropriately (e.g. antihistamines, SQ epinephrine, etc).  3. With appropriate treatment, it is usually possible to restart the IV infusion within one hour, and there appears to be a very low incidence of recurrence of symptoms after the infusion is restarted.  4. Consultation with a poison center is recommended prior to restarting the infusion.
		0.05 gm/kg, INT, IVPB, Q4H, T;N+60, duration: 1 Dose(s)/Time(s)
			Comment: In D5W 500 mL. Infuse over 4hr.  Bag 2 of 3 Max Dose = 5gm (dosing weight max = 100kg)
		0.1 gm/kg, INT, IVPB, Q16H, T;N+300, duration: 1 Dose(s)/Time(s)
			Comment: In D5W 1,000 mL.  Infuse over 16  hours.  Bag 3 Check labs before hanging additional bags.  Max Dose 10gm (dosing weight max = 100kg)
Medications
Patient Care
	No Acetaminophen
		T;N
	Discontinue IV Fluids Conditional
		T;N+1260, Once, See Order Comments
			Comment: If APAP < 10mcg/mL, AST & ALT normal or improving (single decline of ~50% or 2 successful declining values) notify provider to order to discontinue Acetylcysteine infusion; If patient does not meet the criteria, notify ordering provider to obtain a new order to continue infusion at the same concentration/rate as bag 3 of 3.

IV Treatment-Late (>8hr,unk APAP ingest)
Laboratory
	ALT
		T;N, Stat, spec type = Blood
	AST
		T;N, Stat, spec type = Blood
	Bilirubin Total
		T;N, Stat, spec type = Blood
	INR - MH/WH/JE
		T;N, Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
	Acetaminophen Level
		T;N, Stat, spec type = Blood
		T;N+720, Timed, Q12H, spec type = Blood
	ALT
		T;N+720, Timed, Q12H, spec type = Blood
	AST
		T;N+720, Timed, Q12H, spec type = Blood
	Bilirubin Total
		T;N+720, Timed, Q12H, spec type = Blood
	INR - MH/WH/JE
		T;N+720, Timed, Q12H, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N+720, Q12H, Timed, spec type = Diagnostic Blood
		T;N+720, Q12H, Timed, spec type = Therapeutic Blood
	Basic Metabolic Panel
		T;N+1260, Routine, spec type = Blood
		T+2;0400, Routine, Q24H, spec type = Blood
	Acetaminophen Level
		T;N+420, Timed, spec type = Blood
			Comment: Obtain level 7 hours after ingestion if APAP was co-ingested with an opioid or anticholinergic and the 4 hr APAP level is < 150mcg/ml; begin acetylcysteine protocol if level > 89mcg/ml, consider if 7 hr level will not be reported within 8 hours of ingestion.
IV Solutions
		Initiation greater than 8 hours post acetaminophen ingestion; unknown time of ingestion, or chronic ingestion-select the following 3 acetylcysteine IVPB orders:(NOTE)*
	acetylcysteine IVPB
		0.15 gm/kg, INT, IVPB, Once, 250 ml/hr, duration: 1 Dose(s)/Time(s)
			Comment: In D5W 250 mL.  Infuse over 60 minutes.  Bag 1 of 3. Max Dose 15g (dosing weight max= 100kg)   1. Monitor closely for bronchospasm and anaphylactoid reactions, especially during the loading dose and in those with risk factors for developing anaphylactoid reactions.  2. Stop the infusion in patients who develop anaphylactoid symptoms. Most reactions are mild and often resolve with temporary cessation of the IV NAC infusion. Reactions that are more than mild should be treated appropriately (e.g. antihistamines, SQ epinephrine, etc).  3. With appropriate treatment of anaphylaxis, it is usually possible to restart the IV infusion within one hour, and there appears to be a very low incidence of recurrence of symptoms after the infusion is restarted.  4. Consultation with a poison center is recommended prior to restarting the infusion.
		0.05 gm/kg, INT, IVPB, Q4H, T;N+60, duration: 1 Dose(s)/Time(s)
			Comment: In D5W 500 ml.  Rate 125ml/hr. Bag 2.  Max Dose 5g (dosing weight max= 100kg).
		0.1 gm/kg, INT, IVPB, Q16H, T;N+300
			Comment: In D5W 1,000 mL.  Infuse over 16  hours.  Bag 3 Check labs before hanging additional bags.  Continue until APAP level < 10mcg/ml and AST/ALT/INR are all normal or improving.  Max Dose 10gm (dosing weight max = 100kg)
Medications
Patient Care
	No Acetaminophen
		T;N
	Discontinue IV Fluids Conditional
		T;N+1680, Once, See Order Comments
			Comment: If APAP < 10mcg/mL, AST & ALT normal or significantly improved from initial values, notify provider for order to discontinue Acetylcysteine infusion; If patient does not meet the criteria, (APAP > 10mcg/mL OR rising liver enzymes OR rising INR in the setting of liver injury, notify ordering provider for further orders and continue infusion at the same concentration/rate as bag 3.

IV Treatment-Very Hi APAP lvl >300mcg/mL
Laboratory
	ALT
		T;N, Stat, spec type = Blood
	AST
		T;N, Stat, spec type = Blood
	Bilirubin Total
		T;N, Stat, spec type = Blood
	INR - MH/WH/JE
		T;N, Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
	Acetaminophen Level
		T;N, Stat, spec type = Blood
		T;N+720, Timed, Q12H, spec type = Blood
	ALT
		T;N+720, Timed, Q12H, spec type = Blood
	AST
		T;N+720, Timed, Q12H, spec type = Blood
	Bilirubin Total
		T;N+720, Timed, Q12H, spec type = Blood
	INR - MH/WH/JE
		T;N+720, Timed, Q12H, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N+720, Q12H, Timed, spec type = Diagnostic Blood
		T;N+720, Q12H, Timed, spec type = Therapeutic Blood
	Basic Metabolic Panel
		T;N+1260, Routine, spec type = Blood
		T+2;0400, Routine, Q24H, spec type = Blood
	Acetaminophen Level
		T;N+420, Timed, spec type = Blood
			Comment: Obtain level 7 hours after ingestion if APAP was co-ingested with an opioid or anticholinergic and the 4 hr APAP level is < 150mcg/ml; begin acetylcysteine protocol if level > 89mcg/ml, consider if 7 hr level will not be reported within 8 hours of ingestion.
IV Solutions
		Select the following 2 acetylcysteine IVPB orders:(NOTE)*
	acetylcysteine IVPB
		0.15 gm/kg, INT, IVPB, Once, 250 ml/hr
			Comment: In D5W 250 mL.  Infuse over 60 minutes.  Bag 1 of 6. Max Dose 15g (dosing weight max= 100kg)   1. Monitor closely for bronchospasm and anaphylactoid reactions, especially during the loading dose and in those with risk factors for developing anaphylactoid reactions.  2. Stop the infusion in patients who develop anaphylactoid symptoms. Most reactions are mild and often resolve with temporary cessation of the IV NAC infusion. Reactions that are more than mild should be treated appropriately (e.g. antihistamines, SQ epinephrine, etc).  3. With appropriate treatment of anaphylaxis, it is usually possible to restart the IV infusion within one hour, and there appears to be a very low incidence of recurrence of symptoms after the infusion is restarted.  4. Consultation with a poison center is recommended prior to restarting the infusion.
		0.05 gm/kg, INT, IVPB, Q4H, T;N+60, duration: 5 Dose(s)/Time(s)
			Comment: In D5W 500 ml.  Rate 125ml/hr. Bags 2-6.  Max Dose 5g (dosing weight max= 100kg). Continue until APAP level < 10mcg/ml; if APAP level < 10mcg/ml but AST/ALT/INR are rising, continue NAC at a reduced rate of 75ml/hr (0.0625gm/kg/hr).
	Discontinue IV Fluids Conditional
		T;N+1260, See Order Comments
			Comment: If APAP < 10mcg/mL, AST & ALT normal or significantly improved from initial values, notify provider for order to discontinue Acetylcysteine infusion; If patient does not meet the criteria, (APAP > 10mcg/mL OR rising liver enzymes OR rising INR in the setting of liver injury, notify ordering provider for further orders and continue infusion at 0.0625mg/kg/hr until hepatic function improves (decreasing INR), transplantation, or death.
Medications
Patient Care
	No Acetaminophen
		T;N
	Discontinue IV Fluids Conditional
		T;N+1260, Once
			Comment: If APAP < 10mcg/mL, AST & ALT normal or significantly improved from initial values, notify provider for order to discontinue Acetylcysteine infusion; If patient does not meet the criteria, (APAP > 10mcg/mL OR rising liver enzymes OR rising INR in the setting of liver injury, notify ordering provider for further orders and continue infusion at 0.0625mg/kg/hr until hepatic function improves (decreasing INR), transplantation, or death

IV Treatment-Two bag Method
Laboratory
	ALT
		T;N, Stat, spec type = Blood
	AST
		T;N, Stat, spec type = Blood
	Bilirubin Total
		T;N, Stat, spec type = Blood
	INR - MH/WH/JE
		T;N, Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
	Acetaminophen Level
		T;N, Stat, spec type = Blood
		T;N+720, Timed, Q12H, spec type = Blood
	ALT
		T;N+720, Timed, Q12H, spec type = Blood
	AST
		T;N+720, Timed, Q12H, spec type = Blood
	Bilirubin Total
		T;N+720, Timed, Q12H, spec type = Blood
	INR - MH/WH/JE
		T;N+720, Timed, Q12H, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N+720, Q12H, Timed, spec type = Diagnostic Blood
		T;N+720, Q12H, Timed, spec type = Therapeutic Blood
	Basic Metabolic Panel
		T;N+1260, Routine, spec type = Blood
		T+2;0400, Routine, Q24H, spec type = Blood
	Acetaminophen Level
		T;N+420, Timed, spec type = Blood
			Comment: Obtain level 7 hours after ingestion if APAP was co-ingested with an opioid or anticholinergic and the 4 hr APAP level is < 150mcg/ml; begin acetylcysteine protocol if level > 89mcg/ml, consider if 7 hr level will not be reported within 8 hours of ingestion.
IV Solutions
	acetylcysteine IVPB
		0.2 gm/kg, INT, IVPB, Once, 125 ml/hr
			Comment: In D5W 500 ml; Infuse over 4hours.  Bag 1 of 2. Max Dose 20g (dosing weight max= 100kg)   1. Monitor closely for bronchospasm and anaphylactoid reactions and in those with risk factors for developing anaphylactoid reactions.  2. Stop the infusion in patients who develop anaphylactoid symptoms. Most reactions are mild and often resolve with temporary cessation of the IV NAC infusion. Reactions that are more than mild should be treated appropriately (e.g. antihistamines, SQ epinephrine, etc).  3. With appropriate treatment of anaphylaxis, it is usually possible to restart the IV infusion within one hour, and there appears to be a very low incidence of recurrence of symptoms after the infusion is restarted.  4. Consultation with a poison center is recommended prior to restarting the infusion.
		0.1 gm/kg, INT, IVPB, Once, 62.5 ml/hr, T;N+240, duration: 1 Dose(s)/Time(s)
			Comment: In D5W 1000 mL. Infuse over 16hr. Bag 2 of 2.  Max Dose 10g (dosing weight max= 100kg)
	Discontinue IV Fluids Conditional
		T;N+1680, Once, See Order Comments
			Comment: If APAP < 10mcg/mL, AST & ALT normal or significantly improved from initial values, notify provider for order to discontinue Acetylcysteine infusion; If patient does not meet the criteria, (APAP > 10mcg/mL OR rising liver enzymes OR rising INR in the setting of liver injury, notify ordering provider for further orders and continue infusion at the same concentration/rate as bag 3.
Medications
Patient Care
	No Acetaminophen
		T;N
	Discontinue IV Fluids Conditional
		T;N+1260, Once
			Comment: If APAP<10mcg/mL, AST & ALT are normal or significantly improved (single decline of ~50% or 2 successful declining values), notify provider for order to discontinue Acetylcysteine infusion; If patient does not meet the criteria (APAP>10mcg/mL OR rising liver enzymes OR rising INR in the setting of liver injury, notify ordering provider for further orders and continue infusion at the same concentration/rate as bag 2 of 2.

Allergy Reaction Protocol
Activity
	Position Patient
		T;N
			Comment: If hypotensive, keep patient supine with legs elevated or bed in trendelenberg
IV Solutions
	Sodium Chloride 0.9%
		500 mL, IV, Routine, Bolus
		1,000 mL, IV, Routine, 30 ml/hr
Medications
	Benadryl
		50 mg, Injection, IV Push, Once, PRN, allergic reaction, NOW
		25 mg, Injection, IV Push, Once, PRN, allergic reaction, NOW
	Decadron (MH/WH)
		20 mg, Injection, IV PUSH, Once, PRN, allergic reaction
	SOLU-Medrol
		125 mg, Injection, IV Push, Once
	EPINEPHrine
		0.5 mg, Injection, SUBCUTANEOUS, Once
		0.5 mg, Injection, IM-Intramuscular, Once
		0.5 mg, Injection, SUBCUTANEOUS, Q10MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.5 mg, Injection, IM-Intramuscular, Q10MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		For infants and children up to age 12 < 30kg(NOTE)*
		0.01 mg/kg, Injection, SUBCUTANEOUS, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.01 mg/kg, Injection, IM-Intramuscular, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		For infants and children up to age 12 > or equal to 30kg(NOTE)*
		0.3 mg, Injection, SUBCUTANEOUS, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.3 mg, Injection, IM-Intramuscular, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
Patient Care
	Pharmacy Consult
		T;N, Allergy Reaction Protocol was entered on this patient, please verify allergy, and add allergen to patient allergies in medical record
	Discontinue Medication
		T;N, Discontinue IV medication or infusion and remove tubing
	Notify MD
		T;N, Contact PCP for additional orders

Allergy Reaction Protocol
Activity
	Position Patient
		T;N
			Comment: If hypotensive, keep patient supine with legs elevated or bed in trendelenberg
IV Solutions
	Sodium Chloride 0.9%
		500 mL, IV, Routine, Bolus
		1,000 mL, IV, Routine, 30 ml/hr
Medications
	Benadryl
		50 mg, Injection, IV Push, Once, PRN, allergic reaction, NOW
		25 mg, Injection, IV Push, Once, PRN, allergic reaction, NOW
	Decadron (MH/WH)
		20 mg, Injection, IV PUSH, Once, PRN, allergic reaction
	SOLU-Medrol
		125 mg, Injection, IV Push, Once
	EPINEPHrine
		0.5 mg, Injection, SUBCUTANEOUS, Once
		0.5 mg, Injection, IM-Intramuscular, Once
		0.5 mg, Injection, SUBCUTANEOUS, Q10MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.5 mg, Injection, IM-Intramuscular, Q10MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		For infants and children up to age 12 < 30kg(NOTE)*
		0.01 mg/kg, Injection, SUBCUTANEOUS, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.01 mg/kg, Injection, IM-Intramuscular, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		For infants and children up to age 12 > or equal to 30kg(NOTE)*
		0.3 mg, Injection, SUBCUTANEOUS, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.3 mg, Injection, IM-Intramuscular, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
Patient Care
	Pharmacy Consult
		T;N, Allergy Reaction Protocol was entered on this patient, please verify allergy, and add allergen to patient allergies in medical record
	Discontinue Medication
		T;N, Discontinue IV medication or infusion and remove tubing
	Notify MD
		T;N, Contact PCP for additional orders

Allergy Reaction Protocol
Activity
	Position Patient
		T;N
			Comment: If hypotensive, keep patient supine with legs elevated or bed in trendelenberg
IV Solutions
	Sodium Chloride 0.9%
		500 mL, IV, Routine, Bolus
		1,000 mL, IV, Routine, 30 ml/hr
Medications
	Benadryl
		50 mg, Injection, IV Push, Once, PRN, allergic reaction, NOW
		25 mg, Injection, IV Push, Once, PRN, allergic reaction, NOW
	Decadron (MH/WH)
		20 mg, Injection, IV PUSH, Once, PRN, allergic reaction
	SOLU-Medrol
		125 mg, Injection, IV Push, Once
	EPINEPHrine
		0.5 mg, Injection, SUBCUTANEOUS, Once
		0.5 mg, Injection, IM-Intramuscular, Once
		0.5 mg, Injection, SUBCUTANEOUS, Q10MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.5 mg, Injection, IM-Intramuscular, Q10MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		For infants and children up to age 12 < 30kg(NOTE)*
		0.01 mg/kg, Injection, SUBCUTANEOUS, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.01 mg/kg, Injection, IM-Intramuscular, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		For infants and children up to age 12 > or equal to 30kg(NOTE)*
		0.3 mg, Injection, SUBCUTANEOUS, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.3 mg, Injection, IM-Intramuscular, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
Patient Care
	Pharmacy Consult
		T;N, Allergy Reaction Protocol was entered on this patient, please verify allergy, and add allergen to patient allergies in medical record
	Discontinue Medication
		T;N, Discontinue IV medication or infusion and remove tubing
	Notify MD
		T;N, Contact PCP for additional orders

Allergy Reaction Protocol
Activity
	Position Patient
		T;N
			Comment: If hypotensive, keep patient supine with legs elevated or bed in trendelenberg
IV Solutions
	Sodium Chloride 0.9%
		500 mL, IV, Routine, Bolus
		1,000 mL, IV, Routine, 30 ml/hr
Medications
	Benadryl
		50 mg, Injection, IV Push, Once, PRN, allergic reaction, NOW
		25 mg, Injection, IV Push, Once, PRN, allergic reaction, NOW
	Decadron (MH/WH)
		20 mg, Injection, IV PUSH, Once, PRN, allergic reaction
	SOLU-Medrol
		125 mg, Injection, IV Push, Once
	EPINEPHrine
		0.5 mg, Injection, SUBCUTANEOUS, Once
		0.5 mg, Injection, IM-Intramuscular, Once
		0.5 mg, Injection, SUBCUTANEOUS, Q10MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.5 mg, Injection, IM-Intramuscular, Q10MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		For infants and children up to age 12 < 30kg(NOTE)*
		0.01 mg/kg, Injection, SUBCUTANEOUS, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.01 mg/kg, Injection, IM-Intramuscular, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		For infants and children up to age 12 > or equal to 30kg(NOTE)*
		0.3 mg, Injection, SUBCUTANEOUS, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
		0.3 mg, Injection, IM-Intramuscular, Q5MIN, PRN, anaphylaxis, 3 Dose(s)/Time(s)
Patient Care
	Pharmacy Consult
		T;N, Allergy Reaction Protocol was entered on this patient, please verify allergy, and add allergen to patient allergies in medical record
	Discontinue Medication
		T;N, Discontinue IV medication or infusion and remove tubing
	Notify MD
		T;N, Contact PCP for additional orders

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase