These pumps automatically change the rate from the bolus to the infusion to eliminate another potential delay or error in administration. Finally, we use programmable smart pumps (BD Alaris, Benton, Dickinson & Co., Franklin Lakes, NJ, USA) set with this standard concentration. 4, 5 Third, the elimination of multiple rate changes simplifies nursing workflow and decreases the risk of administration errors. 2, 3 Second, the use of a single bag eliminates the need to order and await delivery of additional bags of NAC, which can lead to significant interruptions in antidotal therapy. This reduces dosing and preparation errors, which are common under the three-bag approach. First, the use of a single standardized concentration of NAC (as opposed to patient-specific concentrations in the three-bag and two-bag approaches) standardizes, simplifies and speeds antidote preparation. After the bolus is complete, we make a single rate change to an infusion of 12.5 mg/kg/h (from the same bag), which continues until the patient meets clinical and laboratory criteria for cessation of antidotal therapy. We administer an initial bolus of 150 mg/kg NAC over 1 hour from this bag. Unlike the standard FDA-approved three-bag regimen and some of the alternative regimens discussed in the editorial, our regimen uses a single standardized concentration of NAC for all patients (30 g of NAC in 1 L of 5% dextrose in water). We have used a one-bag NAC regimen for almost two decades. While we appreciate the authors' clear and succinct review of this exciting field, they omitted discussion of an important alternative NAC regimen that deserves readers' attention. We read with interest the recent commentary by Isbister and Chiew 1 reviewing recent developments in the use of N-acetylcysteine (NAC) for the treatment of acetaminophen (APAP) toxicity.
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