Survival After Methemoglobinemia Associated with Massive Paracetamol Ingestion: A Case Report and Review of the Literature

Introduction: Paracetamol is a frequently used agent in intoxications and known to cause hepatic failure. However, methemoglobinemia secondary to paracetamol toxicity has only been described in a handful of case reports and may be an important determining factor for morbidity and mortality. Methemoglobinemia results in functional anemia with cellular hypoxia. Severe cases are usually fatal. Case Presentation: We present a case of survival after severe methemoglobinemia in a 67-year-old female. She was admitted to the Intensive Care Unit after auto-ingestion of a large amount of paracetamol. Hemoglobin-oximetry showed a methemoglobin level of 24.6%, treated with intravenous methylene blue, exchange-transfusion, ascorbic acid, and riboflavin. Toxicological screening revealed a high plasma concentration of paracetamol (611.7 mg/L). Treatment with N-acetylcysteine (NAC) was initiated. The patient deteriorated and developed acute liver failure, but refused liver transplantation. Furthermore, she developed septic shock with multi-organ failure and bowel ischemia. In spite of her severe condition and her refusing transplantation, the patient survived. There was a complete resolution of acute liver failure and she fully recovered from her critical condition. Conclusions: A case of survival after paracetamol-induced methemoglobinemia is presented. Paracetamol-induced methemoglobinemia seems to be a rare (but possibly under-diagnosed) condition. With this report, we would like to focus more attention on the possibility of methemoglobinemia associated with paracetamol intoxication and emphasize the possible impact on morbidity and mortality. Therefore, we think there should be a low threshold for screening for this rare but hazardous problem when there is clinical suspicion

From therapeutic hypothermia towards targeted temperature management: a decade of evolution

More than a decade after the first randomised controlled trials with targeted temperature management (TTM), it remains the only treatment with proven favourable effect on postanoxemic brain damage after out-of-hospital cardiac arrest. Other well-known indications include neurotrauma, subarachnoidal haemorrhage, and intracranial hypertension. When possible pitfalls are taken into consideration when implementing TTM, the side effects are manageable. After the recent TTM trials, it seems that classic TTM (32−34°C) is as effective and safe as TTM at 36°C. This supports the belief that fever prevention is one of the pivotal mechanisms that account for the success of TTM. Uncertainty remains concerning cooling method, timing, speed of cooling and rewarming. New data indicates that TTM is safe and feasible in cardiogenic shock, one of its classic contra-indications. Moreover, there are limited indications that TTM might be considered as a therapy for cardiogenic shock per se