DRUG GUIDELINE

PARACETAMOL (Intravenous Infusion)

SCOPE (Area): FOR USE IN: All Wards excluding neonates
EXCLUSIONS: neonates (see DRG0037 Neonatal Drug Guideline-
Paracetamol)
SCOPE (Staff): Medical, Nursing and Pharmacy

BRAND NAMES
Various brands of IV paracetamol are available.
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PHARMACOLOGY AND PHARMACOKINETICS

Paracetamol has analgesic and antipyretic actions in the central nervous system. It inhibits
prostaglandin synthetase in the hypothalamus, prevents synthesis of spinal prostaglandin, and
inhibits inducible nitric oxide synthesis in macrophages. In therapeutic doses, inhibition of
prostaglandin synthesis is not significant in peripheral tissues, so paracetamol has minimal anti-
inflammatory action.
Intravenous paracetamol infusion provides onset of pain relief within five to ten minutes after the
start of administration. The peak analgesic effect is obtained in one hour and the duration of this
effect is usually four to six hours. Fever is reduced within 30 minutes after the start of
administration, with a duration of the antipyretic effect of at least six hours. Oral paracetamol has a
high bioavailability and can be regarded as interchangeable with intravenous. Paracetamol has an
elimination half-life of 1 to 3 hours and undergoes extensive first-pass metabolism in the liver, with
the kidneys excreting its metabolites.
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INDICATIONS
 For the relief of mild to moderate pain (and in an opioid sparing capacity) where the enteral
route of administration is not clinically appropriate (e.g. lack of gastrointestinal
form/function such as ileus, vomiting, severe diarrhoea, nil by mouth).
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CONTRAINDICATIONS
 Hypersensitivity to paracetamol or to any of the excipients.
 Patients with severe hepatocellular insufficiency, hepatic failure or decompensated active
liver disease.
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PRECAUTIONS
 Chronic liver disease or non-severe hepatocellular insufficiency - these patients may be at
increased risk of hepatic damage following therapeutic dose or overdose of paracetamol,
although evidence is lacking. Consider giving doses no more often than every 6 hours.

DRG0020: Paracetamol (Intravenous Infusion) Ratification Date: April 2020

Review Date: April 2025 Version 5
UNCONTROLLED COPY IF PRINTED Page: 1 of 4 See BHS Intranet for current version
Note: Hepatotoxicity can occur following paracetamol overdose (acute or chronic). Although a
number of factors have been proposed to increase the risk of liver toxicity following acute overdose,
evidence to support them is weak; they include depleted glutathione stores (e.g. prolonged fasting
or malnutrition), treatment with hepatic enzyme inducers, severe renal, hepatic or cardiac
impairment, dehydration and chronic alcohol intake. There is no evidence that these factors increase
risk of liver toxicity following therapeutic doses of paracetamol.
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PREGNANCY AND BREASTFEEDING

Seek specialist advice before prescribing, information may update regularly.
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DRUG INTERACTIONS
 Dasatinib, imatinib, isoniazid, sorafenib - paracetamol increases the hepatotoxicity of these
drugs, avoid paracetamol where possible.
 Probenecid - can increase paracetamol levels and levels of its toxic metabolite, avoid
paracetamol where possible.
 Carbamazepine, ethanol, phenobarbitone, phenytoin, primidone - these liver enzyme
inducing drugs can increase the metabolism of paracetamol both reducing effectiveness and
increasing the level of toxic metabolite leading to an increased risk of hepatotoxicity. Avoid
large or chronic doses of paracetamol with patients taking these drugs.
 Busulfan - paracetamol may increase busulfan levels if used in the 72 hours prior to dosing.
 Lamotrigine - paracetamol may decrease the serum concentration of lamotrigine with higher
doses longer than several days.
 Warfarin - weak and conflicting evidence suggests that regular use of paracetamol may increase
the INR, increasing the risk of bleeding; consider monitoring the INR and decrease warfarin dose
if needed.
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DOSAGE AND ADMINISTRATION

Paracetamol is generally considered a safe analgesic with a low incidence of adverse effects
compared with other drugs.

Intravenous and enteral doses are equivalent (providing absorption is adequate). Enteral is
the preferred route of administration and should be given wherever possible/practicable.
Where both enteral and intravenous routes are ordered, Nursing Staff are required to
record which route was administered for each dose. When intravenous paracetamol is
ordered, the Prescriber must review after every 48 hours of therapy to determine when a
change to enteral dosing is appropriate.

Always ensure the patient is not receiving any other paracetamol containing products, and the 24
hour maximum dose of paracetamol for each patient is not exceeded.

IV infusion:
Use pre-filled vial 1000 mg/100 mL, no dilution is required.
Infuse dose (as calculated in table below) intravenously over 15 minutes.
Where doses less than a full vial are required (i.e. weight less than 50 kg), draw up the exact dose
from the vial for administration via a syringe attachment OR if a syringe attachment is not practical
(e.g. volume above 50 mL) withdraw and discard the amount not required from the vial before
administration.
Concentration: 10 mg/mL.

DRG0020: Paracetamol (Intravenous Infusion) Ratification Date: April 2020

Review Date: April 2025 Version 5
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Note: There is sometimes pain noted at the site of the infusion (2%). This is usually quite minor and
should be managed by slowing the infusion. If it is a major concern, the Acute Pain Service should
be called.

ADULT INTRAVENOUS PARACETAMOL DOSING CALCULATION TABLE

Dosing is based on actual body weight
Doses should be prescribed in milligrams (mg)
The maximum daily dose includes all medicines containing paracetamol
PATIENT WEIGHT PARACETAMOL Minimum interval Maximum Total Dose in 24
DOSE between each hours (exceeding this dose
per administration administration - or may result in severe hepatic
dose interval injury)
50 kg or greater 1000 mg 6 hours 4000 mg

Maximum 4 doses in
24 hours

Less than 50 kg 15 mg/kg 6 hours 60 mg/kg

Maximum 4 doses in
24 hours

PAEDIATRIC (1 month to less than 18years#) INTRAVENOUS PARACETAMOL

DOSING CALCULATION TABLE
Dosing is based on actual body weight, except in obese children*
Doses should be prescribed in milligrams (mg)
The maximum daily dose includes all medicines containing paracetamol
PATIENT WEIGHT PARACETAMOL Minimum interval Maximum Total Dose in 24
DOSE between each hours (exceeding this dose
per administration administration - or may result in severe hepatic
dose interval injury)
50 kg or greater* 1000 mg 6 hours 4000 mg

Maximum 4 doses in
24 hours
Less than 50 kg* 15 mg/kg 6 hours 60 mg/kg

Maximum 4 doses in
24 hours
* If the child is obese, use ideal weight or the average weight-for-age dose recommendation on the product label
#
For neonates see DRG0037 Neonatal Drug Guideline - Paracetamol

General Administration Information

 Infusion pump: AlarisTM LVP or syringe attachment with Guardrails
 Routes of administration:
IV injection: No
IV intermittent infusion: Yes (over 15 minutes)
IV continuous infusion: No
IM injection: No
Subcut injection: No

DRG0020: Paracetamol (Intravenous Infusion) Ratification Date: April 2020

Review Date: April 2025 Version 5
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 Compatible/incompatible IV drugs/fluids:
Consult the Australian Injectable Drugs Handbook (‘Yellow book’) in your ward area. Assume
all unlisted drugs and IV fluids are incompatible – contact Pharmacy for further advice.
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MONITORING (INCLUDING BLOOD TESTS)

 Nil.
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NURSING PRACTICE POINTS

 As intravenous paracetamol comes in a glass bottle, a vented administration set should be used,
or a long airway needle inserted into the bung.
 There is a plastic bottle hanger fixed to the plastic label of the paracetamol bottle, which can be
peeled away to hang the bottle.
 Paracetamol should not be infused whilst other drugs are being administered or be mixed with
other drugs.
 Paracetamol is compatible with sodium chloride 0.9%, glucose 5% or compound sodium lactate
(Hartmann's solution) - either infuse through a separate IV line, or via the sideline of a sodium
chloride 0.9%, glucose 5% or compound sodium lactate infusion. (Note: the Australian
Injectable Drugs Handbook (‘Yellow book’) does not list paracetamol as being compatible with
compound sodium lactate, but other references do).
 Ensure bung is pierced at the area where the bung is thinnest to help prevent the bung becoming
fragmented or pushed into the vial.
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ADVERSE EFFECTS
 Common - administration site reaction (especially in children), administration site pain,
increased aminotransferases (especially if doses of 4 g/day are used for longer than 4 days).
 Rare - nausea, vomiting, tachycardia, hypersensitivity reactions (e.g. rash, fixed drug eruption,
toxic epidermal necrolysis and Stevens-Johnson syndrome), neutropenia, thrombocytopenia,
pancytopenia, acute hepatitis, hypotension
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DRUG PRESENTATIONS, LOCATION AND STORAGE

Paracetamol 1000 mg/100 mL vials.
Store below 25°C.
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DRG0020: Paracetamol (Intravenous Infusion) Ratification Date: April 2020

Review Date: April 2025 Version 5
UNCONTROLLED COPY IF PRINTED Page: 4 of 4 See BHS Intranet for current version