Haemodynamic changes with paracetamol in critically-ill children

Abstract

Purpose: Paracetamol has been associated with a reduction in blood pressure, especially in febrile, critically-ill adults. We hypothesised that blood pressure would fall following administration of paracetamol in critically-ill children and this effect would be greater during fever and among children with a high body surface area to weight ratio. Methods:A 12-month prospective observational study of children (0-16 years) admitted to paediatric intensive care, who underwent pulse contour analysis and received paracetamol concurrently. Results:Mean arterial blood pressure decreased significantly by 4.7% from baseline (95% CI 1.75-8.07%) in 31 children following 148 doses of paracetamol. The nadir was 2-hours postdose. The effect was pronounced in children with fever at baseline (6.4%, 95% CI 2.8-10%), although this was not statistically significant. There was no simple relationship between this effect and body surface area to weight ratio. The association between a change in blood pressure and changes in heart rate or measured stroke volume was poor; therefore it was likely that a change in the systemic vascular resistance contributes most to this effect. Conclusion:There is a significant but modest reduction in blood pressure post-paracetamol in critically-ill children. This is likely related to a change in systemic vascular resistance.

Hemodynamic effects of intravenous paracetamol in critically ill children with septic shock on inotropic support

“…Similarly, a study in children after cardiac surgery found that 1 in every 20 administrations of paracetamol (5%) was associated with a 15% drop in MAP from baseline [13]. However, this study, like the previous one [12], evaluated the change in MAP, not true hypotension.…”

“…Ray et al [12] reported a mean decrease of 4.8% (3.3 mmHg) in MAP from baseline (68 mmHg) in critically ill children. However, they included all routes of paracetamol administration, which may affect drug delivery and MAP change, and the reported decrease in MAP per se, which does not indicate true hypotension.…”

“…The authors concluded that impaired hemodynamics in a neonate is a relative contraindication for intravenous paracetamol. Others, using pulse contour analysis, reported a significant, 4.7% reduction in MAP in critically ill children after paracetamol administration which they attributed to systemic vascular resistance [12]. Similarly, a study in children after cardiac surgery found that 1 in every 20 administrations of paracetamol (5%) was associated with a 15% drop in MAP from baseline [13].…”

Fever: Could A Cardinal Sign of COVID-19 Infection Reduce Mortality?

“…A key mechanism for lowering temperature is by initiation of cutaneous vasodilation, [50][51][52] similar to what occurs during defervescence, which facilitates arterial heat dissipation from the skin. This vasodilation can occur to varying degrees in a febrile patient, but studies in both adults [53][54][55] and children 56,57 have shown this often leads to a clinically significant fall in mean arterial pressure. The subsequent acetaminophen-induced hypotension is then countered with fluid and/or vasopressor support to maintain adequate organ perfusion.…”

“…The subsequent acetaminophen-induced hypotension is then countered with fluid and/or vasopressor support to maintain adequate organ perfusion. [53][54][55][56][57] Thus, a vicious cycle ensues as we desperately work against the normal physiology of the body to maintain blood pressure, but as total body water stores increase, oxygenation in the lungs then becomes compromised, inducing unnecessary harm. 58 The time for an evidence-based approach to fluid management in the febrile patient is long overdue.…”