Calling all peds/ER nurses RE: Tylenol dosage

Double-Helix, BSN, RN · Feb 10, 2012

We use 10-15 mg/kg/dose with a max of 650mg per dose (adult dose) every 4-6 hours. It's our responsibility as nurses in the PICU to verify that the ordered dose is safe for the patient. If I received an order for a hepatotoxic dose I would question it and not administer without a very, very good reason. To my knowledge, there is no benefit to giving more than the recommended dose of Tylenol and overdosing Tylenol can have serious consequences.

noahsmama · Feb 10, 2012

I agree with Ashley that I'm not aware of any circumstances in which a potentially hepatotoxic dose of acetaminophen would be given deliberately -- I am not aware of any benefits of the medication which would outweigh the risks. It's been a while since I worked in a hospital, but in addition to have a maximum amount per dose (10-15 mg/kg/dose sounds about right), we also had a daily maximum that I believe worked out to no more than 4 doses per day, so even if it was ordered q4 PRN, which in theory means you could give 6 doses per day, in practice we didn't give more than 4 per day. The max included not just acetaminophen given by itself, but contained in other medications (e.g. vicodin, tylenol with codeine, etc.)

The only time I've seen a child who had received a hepatotoxic dose is when I had a few teenaged patients who had deliberately taken a whole bottle of tylenol as a suicide gesture. These patients would get a course of mucomyst, the antedote to tylenol poisoning.

6spdftwtm · Feb 11, 2012

I had just recently left an assignment in Houston where ANY febrile child would receive a 500mg suppository in triage "per protocol"...regardless of age or weight. The physicians would routinely give orders for the same.

"Give the kid some Tylenol."

"How much, doc...15mg/kg."

"Eh...give them 30mg/kg...actually make it 45mg/kg."

"Are you sure...that seems like a massive dose for a little immature liver."

"Oh it's fine...a one-time dose won't hurt them."

So, I never would. They were given 15mg/kg. Haven't seen a place since then that did this.

Late,

Trav

wooh, BSN, RN · Feb 11, 2012

Recommendations have actually gone down. Used to be 10-15mg/kg per kilo. Now we're leaning towards 10mg per kilo for regular dosing. (Recommendations for lowering tylenol doses that recently came about.) But if we've got a fever we just can't kick, we'll do the occasional 15mg/kg dose.

I've never seen a serious OD (in the hospital by staff, seen plenty of "suicide attempts" by attention seeking teens that were ridiculously high ODs.) I know I've seen mixups of the wrong dose hitting 20mg/kg and the occasional dose given a couple hours early. But if you stick to the 10-15 range, you're generally safe.

KelRN215, BSN, RN · Feb 11, 2012

We generally abide by 10-15 mg/kg with a maximum daily dose of 75 mg/kg/day. I believe the order-set contains a sentence that says something like "maximum daily dose 75 mg/kg/day from all sources."

I have never seen a hepatotoxic dose of tylenol given nor have I seen hepatotoxicity develop after several days of tylenol use. We occasionally have children who come in with febrile seizure who have some underlying virus who are on tylenol/motrin atc for a few days.

hiddencatRN, BSN, RN · Feb 12, 2012

Our protocol is 15mg/kg/dose. The only hepatotoxic doses I've seen have been ODs/ingestions that come in to us.

platon20 · Feb 12, 2012

I almost never order tylenol because a fever is not that big of a deal unless:

1) child is so irritable he refuses to eat or sleep (if he's really that irritable you can make a strong argument he needs a lumbar puncture and antibiotics)

2) fever is outrageously high (rectal temp 105 or higher).

Those are really the only indications to treat a fever IMHO. If a 1 month old baby has a fever of 102 but is sleeping fine and eating OK, there's absolutely no reason to treat it with tylenol.

The pattern of a fever can be a great diagnostic clue as to whats going on, and if you artificially suppress it with tylenol it can sometimes make the diagnosis harder.

In your experiences...
What is acceptable practice for a one-time dosage of acetaminophen?
What is acceptable practice for q4hr administration?
Have you ever seen a child that received a one-time hepatotoxic dose (
What about hepatotoxic doses received over multiple doses in a 1-2 day timeframe?
Late,
Trav

Twinmom06, ASN, APN · Feb 12, 2012

I almost never order tylenol because a fever is not that big of a deal unless:
1) child is so irritable he refuses to eat or sleep (if he's really that irritable you can make a strong argument he needs a lumbar puncture and antibiotics)
2) fever is outrageously high (rectal temp 105 or higher).
Those are really the only indications to treat a fever IMHO. If a 1 month old baby has a fever of 102 but is sleeping fine and eating OK, there's absolutely no reason to treat it with tylenol.
The pattern of a fever can be a great diagnostic clue as to whats going on, and if you artificially suppress it with tylenol it can sometimes make the diagnosis harder.

I'm not a nurse yet, but I do have children and the pediatric guideline in a baby that young was a fever over 100 was a HUGE deal and needed to be admitted to the hospital - has that guideline changed?

Jolie, BSN · Feb 12, 2012

I'm not a nurse yet, but I do have children and the pediatric guideline in a baby that young was a fever over 100 was a HUGE deal and needed to be admitted to the hospital - has that guideline changed?

Fever in a young infant is always cause for concern because young infants' immune systems are very immature and can't be trusted to function the same way that an older child's or adult's would.

This means that all fevers in young babies must be evaluated. Based upon the evaluation, it may be determined that the fever signals a possible infection requiring treatment with antibiotics.

Deciding to treat a possible infection is very different than deciding to treat a fever. Generally, speaking, fever is a useful tool in fighting infection. Unless the fever is causing the child discomfort or is so high as to pose the risk of febrile seizures, giving Tylenol or other meds to treat the fever may not be the best course of action.

A baby with a temp. of 102 who is eating and sleeping normally may not benefit from Tylenol. A baby with a temp. of 100 who is fussy and unable to nurse might.

Twinmom06, ASN, APN · Feb 12, 2012

Fever in a young infant is always cause for concern because young infants' immune systems are very immature and can't be trusted to function the same way that an older child's or adult's would.
This means that all fevers in young babies must be evaluated. Based upon the evaluation, it may be determined that the fever signals a possible infection requiring treatment with antibiotics.
Deciding to treat a possible infection is very different than deciding to treat a fever. Generally, speaking, fever is a useful tool in fighting infection. Unless the fever is causing the child discomfort or is so high as to pose the risk of febrile seizures, giving Tylenol or other meds to treat the fever may not be the best course of action.
A baby with a temp. of 102 who is eating and sleeping normally may not benefit from Tylenol. A baby with a temp. of 100 who is fussy and unable to nurse might.

Thank you for clarifying!

hiddencatRN, BSN, RN · Feb 12, 2012

I'm not a nurse yet, but I do have children and the pediatric guideline in a baby that young was a fever over 100 was a HUGE deal and needed to be admitted to the hospital - has that guideline changed?

No, those patients often get a full septic workup in our ER even if there's a likely source (RSV). 1 month old with a fever is most certainly a BFD.