Acetaminophen use, liver damage, and ICU

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Nursing student here:

I just did my clinicals in ICU this past week and have a question regarding the use of acetaminophen. One of my patients was a post v-fib cardiac arrest, intubated, RASS -5, on fentanyl and propofol. Downtime before they got ROSC was 38 min, so he was on hypothermic protocols. Entire situation was most likely due to abrupt EtOH w/d as he had a history of alcoholism; bystander reported seizure before he went into cardiac arrest. Liver enzymes are through the roof. No fever, and we were cooling him down to 33 degrees.

Can someone tell me the rationale behind an order for acetaminophen? Was this strictly a secondary pain medication? There were obviously bleeding concerns since we had him hypothermic, so is this a better choice than an NSAID or something?

I meant to discuss this with my preceptor but it got crazy insane on the floor and I never got a chance. I don't think either one of us even took a bathroom break until at least 7 hours into the shift, lol.

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Was the acetaminophen scheduled or PRN?

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scheduled, liquid PO q6h

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Part of routine hypothermia protocol maybe? Tylenol would be almost be universally avoided in this patient if he didn't have a heart attack, let alone with severely impaired liver function.

Certainly worth clarifying with the person that wrote the order. Whatever the reason, it couldn't have been integral to the overall objectives of his therapy.

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OMG, thank you!! This pt probably really did not need this (pretty extensive anoxic brain injury, extremely poor prognosis, absolutely zero signs of reflexes, including shivering) but that makes so much more sense than just for pain.

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The real question is why are you cooling to 33? There is a ton of good evidence that cooling to 33 leads to increased complications without better outcomes.

This is a pretty good review of the latest study but your resuscitation committee should be looking at the protocol.

PulmCrit Wee - Pragmatic comparison of 33C vs. 36C after cardiac arrest

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I couldn't tell you, as that was my first experience with therapeutic hypothermia and there wasn't much time to delve into the ins and outs of it....I find that article interesting though, since 36 was what we were maintaining at as "normo-thermic" after the rewarming process.

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The real question is why are you cooling to 33? There is a ton of good evidence that cooling to 33 leads to increased complications without better outcomes.

Most places I've worked used 33. However, that research is now being acknowledged and protocols are changing and ICU attendings are on board with the new research showing that such extensive cooling isn't better. It just goes to show how in critical care medicine they make these huge complicated protocols based on small case studies then a few years later it all changes.

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Specializes in Pediatric Hematology/Oncology.

To add on to the debate regarding normothermia vs. hypothermia after cardiac arrest, acetaminophen is used around the clock to prevent fever. The understanding that is gradually coming to light is that it's best to be at a normal temperature so aggressive fever prevention is a priority.

Notice that these slides from the Cleveland Clinic state to avoid the use of acetaminophen in patients w/ known liver dysfunction:

https://my.clevelandclinic.org/ccf/media/Files/nursing/2014-dicc-handouts/Session8_1030_1103_Klein.pdf?la=en

You can still use Tylenol as an antipyretic in patients w/ liver issues. Fulminant liver failure is generally a no-no and dose-reduction (i.e. no more than 2,000 mg/day) can be considered for patients w/ less severe liver problems. Source: I am a peds hemonc nurse - liver cancer kids definitely get Tylenol over Motrin because the risk of bleeding is a much greater concern than any additional liver damage (and you can bet they are dose-reduced).

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Specializes in ICU, trauma, neuro.

Acetaminophen both oral and IV can play an important role in pain management in the ICU. However, with regard to the specific patient that you reference I wouldn't consider giving it. You have "shocked liver" compounded by chronic ETOH which further predisposes the patient to liver damage. In many ICU settings it has an advantage over drugs (NSAIDS) like aspirin, ibuprofin, and naproxen in that it won't promote bleeding or create additional GI stress/bleed potential. This client should also have CIWA protocol with PRN Ativan and or Librium as the patient is weaned off the drips over the coming days. This is the sort of situation that should be flagged by "expert systems" in Pharmacy that look at history and co-morbidities rather than just allergies. Of course its nice when doctors and nurses catch these sort of things as well. Never assume that just because a drug is ordered that it is the best choice or is even safe.

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Specializes in ICU, trauma.

At this point in the game, you have to prioritize. Like some previous posters have stated tylenol is protocol for many places when using post-code hypothermia. IMO i would 100% give the tylenol to help achieve appropriate hypothermia status in hopes that we are able to regain neurological status. Although the liver is very important, i would call it secondary in this situation.

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