ACETYLCYSTEINE

ACETYLCYSTEINE
(a-se-til-sis'tay-een)
Airbron , Mucomyst, Mucosol, N-Acetylcysteine, Acetadote, Acys-5
Classifications: mucolytic agent; antidote;
Therapeutic:mucolytic
; antidote
Pregnancy Category: B

Availability

10%, 20% solution for inhalation; 20% solution for injection

Action

Acetylcysteine probably acts by disrupting disulfide linkages of mucoproteins in purulent and nonpurulent bronchial secretions. In acetaminophen overdose, it helps to prevent hepatotoxicity by serving as a substrate for the toxic metabolites of acetaminophen.

Therapeutic Effect

Lowers viscosity and facilitates the removal of secretions.

Uses

Adjuvant therapy in patients with abnormal, viscid, or inspissated mucous secretions in acute and chronic bronchopulmonary diseases, and in pulmonary complications of cystic fibrosis and surgery, tracheostomy, and atelectasis. Also used in diagnostic bronchial studies and as an antidote for acute acetaminophen poisoning.

Unlabeled Uses

As an ophthalmic solution for treatment of dry eye (keratoconjunctivitis sicca); as an enema to treat bowel obstruction due to meconium ileus; prevention of radiocontrast-induced renal dysfunction.

Contraindications

Hypersensitivity to acetylcysteine; patients at risk of gastric hemorrhage.

Cautious Use

Patients with asthma, older adults, severe hepatic disease, esophageal varices, peptic ulcer disease; debilitated patients with severe respiratory insufficiency, pregnancy (category B), lactation.

Route & Dosage

Mucolytic
Adult: Inhalation 1–10 mL of 20% solution q4–6h or 2–20 mL of 10% solution q4–6h Direct Instillation 1–2 mL of 10–20% solution q1–4h
Child: Inhalation 3–5 mL of 20% solution or 6–10 mL of 10% solution 3–4 times/d
Infant: Inhalation 1–2 mL 20% solution or 2–4 mL of 10% solution 3–4 times/d

Acetaminophen Toxicity
Adult/Child: PO 140 mg/kg followed by 70 mg/kg q4h for 17 doses (use a 5% solution)
Adult/Adolescent/Child: IV 150 mg/kg infused over 60 min, followed by 50 mg/kg over 4 h, then 100 mg/kg over 16 h; total dose 300 mg/kg over 21 h

Administration

Inhalation and Instillation
  • Prepare dilution within 1 h of use; drug does not contain an antimicrobial agent. A light purple discoloration does not significantly impair drug's effectiveness.
  • Dilute the 20% solution with NS or water for injection. The 10% solution may be used undiluted.
  • Give by direct instillation into tracheostomy (1–2 mL of 10–20% solution).
  • Instruct patient to clear airway, if possible, coughing productively prior to aerosol administration to ensure maximum effect.
  • Store opened vial in refrigerator to retard oxidation; use within 96 h.
  • Store unopened vial at 15°–30° C (59°–86° F), unless otherwise directed.
Oral
  • Dilute the 20% solution 1:3 with cola, orange juice, or other soft drink to make a 5% solution. If administered via a gastric tube, water may be used as the diluent.
  • Freshly prepare all diluted solutions and use within 1 h of preparation.
Intravenous

PREPARE: IV Infusion: Acetylcysteine reacts with certain metals and rubber; use IV equipment made of plastic or glass. Dilute all required doses in D5W as follows: for loading dose, add a dose equal to 150 mg/kg to 200 mL; for first maintenance dose, add a dose equal to 50 mg/kg to 500 mL; for second maintenance dose, add a dose equal to 100 mg/kg to 1000 mL. Note: The total IV volume should be reduced for patients <40 kg and for those with fluid restriction. In small children, individualize the total IV volume to avoid water intoxication and hyponatremia.  

ADMINISTER: IV Infusion: Give loading dose over 60 min, maintenance dose 1 over 4 h, maintenance dose 2 over 16 h.  

INCOMPATIBILITIES Y-site: Cefepime, ceftazidime.

  • Store reconstituted solution for up to 24 h at 15°–30° C (59°–86° F).

Adverse Effects (≥1%)

CNS: Dizziness, drowsiness. GI: Nausea, vomiting, stomatitis, hepatotoxicity (urticaria). Respiratory: Bronchospasm, rhinorrhea, burning sensation in upper respiratory passages, epistaxis.

Pharmacokinetics

Onset: 1 min after inhalation or instillation. Peak: 5–10 min. Metabolism: Deacetylated in liver to cysteine.

Nursing Implications

Assessment & Drug Effects

  • During IV infusion, carefully monitor for fluid overload and signs of hyponatremia (i.e., changes in mental status).
  • Monitor for S&S of aspiration of excess secretions, and for bronchospasm (unpredictable); withhold drug and notify physician immediately if either occurs.
  • Lab tests: Monitor ABGs, pulmonary functions and pulse oximetry as indicated: baseline serum acetaminophen level (for toxicity), LFTs, bilirubin, serum electrolytes, BUN, and plasma glucose.
  • Have suction apparatus immediately available. Increased volume of respiratory tract fluid may be liberated; suction or endotracheal aspiration may be necessary to establish and maintain an open airway. Older adults and debilitated patients are particularly at risk.
  • Nausea and vomiting may occur, particularly when face mask is used, due to unpleasant odor of drug and excess volume of liquefied bronchial secretions.

Patient & Family Education

  • Report difficulty with clearing the airway or any other respiratory distress.
  • Report nausea, as an antiemetic may be indicated.
  • Note: Unpleasant odor of inhaled drug becomes less noticeable with continued use.

Common adverse effects in italic, life-threatening effects underlined; generic names in bold; classifications in SMALL CAPS; Canadian drug name; Prototype drug

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