Pediatric Intravenous Acetaminophen Overdoses: A Continuing Iatrogenic Problem

To determine if intravenous (IV) acetaminophen use in children remains a source of iatrogenic overdosing.

A cluster of 3 index cases in early 2025 stimulated a 14-year (2011-2024) retrospective study of calls from health care facilities to the California Poison Control System (CPCS) involving IV acetaminophen dosing errors in children aged 16 years or younger. All calls during this period that involved pediatric IV acetaminophen were reviewed and data abstracted. Date of call, age of child, location in the hospital, laboratory results, acetaminophen levels, intended dose, dose given, use of N-acetylcysteine (NAC), and outcomes were recorded. Descriptive statistics were used.

The 3 index pediatric cases of IV acetaminophen overdose ranged from 3 to 10 times the desired dose. Two of the 3 patients were treated with NAC. The retrospective review of CPCS calls resulted in 42 additional cases in which intravenous dosing errors occurred with mean doses of 45.5 ± 36.7 mg/kg (range, 14.7-147.1 mg/kg) and mean age of 4.9 years ± 4.0 (1 day to 16 years). Two additional patients were treated with NAC. These adverse events happened in operative/perioperative areas (13 cases), 11 cases on the pediatric inpatient units, 5 in intensive care units, 12 in the emergency department, and 4 in unknown areas. No long-term adverse effects were seen in the 45 children.

Rare pediatric iatrogenic IV acetaminophen overdoses continue to be seen in acute care settings. Determining potential toxicity and the need for NAC remains challenging. Further efforts are needed to prevent this infrequent serious medication error.