Steven A. Seifert, MD, FAACT, FACMT, FEAPCCT, is a Professor at the University of New Mexico School of Medicine, the Medical Director of the New Mexico Poison and Drug Information Center, and Editor in Chief of Clinical Toxicology. He is certified in Medical Toxicology by the American Board of Emergency Medicine. He is a Fellow of the American Academy of Clinical Toxicology, the European Association of Poison Centers and Clinical Toxicologists, and the American College of Medical Toxicology. He was previously a Fellow of the American College of Emergency Physicians. He has published over 200 articles of original scientific research, reviews, book chapters, editorials and other scholarly works, including a number of primary research papers on acetaminophen.
Introduction: The standard management of acetaminophen overdose and/or acetaminophen-associated hepatic injury includes the intravenous administration of acetylcysteine in a three-bag regimen. Two-bag, and one-bag administration methods have been explored for optimal efficacy, avoidance of adverse reactions, and minimization of medical errors.
Review of studies: The three-bag method involves extemporaneously compounding three intravenous preparations and infusing them for one-hour, four-hours, and 16-hours, sequentially. The two-bag method, with a modified/slowed initial dose rate has been studied extensively. There is a significant reduction in acute allergic reactions compared with the three-bag method. In addition, there are fewer compounding and administration rate errors, and interruption-related events with the two-bag method, without a difference in efficacy, compared with the three-bag method. A one-bag method reduces preparation time and reduces interruptions in therapy and provides a higher dose of acetylcysteine. Combined with programmable pumps, dose rate errors may also be further reduced. This regimen has a reduced acute allergic reaction rate and decreased dose error rate, without a difference in efficacy compared to the three-bag method.
Conclusions: Two-bag and one-bag acetylcysteine administration protocols can reduce compounding and dose rate errors and antidote interruption events, without a reduction in efficacy, compared with the three-bag method. Acute allergic reactions may be reduced by a slower initial infusion rate. The optimal regimen(s) for safety, efficacy, error reduction, and administration interruption requires additional study, but it is clear that the three-bag method is not optimal for any of these purposes.
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