LAUSR

three-bag IV NAC was initially studied [2]. Based on these results the author report that the absence of unexpected hepatotoxicity may be due to the low risk cohort included in this study. It is important to remember that the three-bag method was designed to match the amount of NAPQI formed from APAP with the amount of glutathione provided by NAC. The author’s proposed dosing regimen would not succeed in providing the needed amount of glutathione early on in a patient more severely poisoned with APAP. Second, the authors report a lower rate of adverse reactions with the two-bag protocol compared to the three bad protocol. In Table 2, the authors list a higher incidence of anaphylactoid reactions (14% vs 5%) and higher use of antiallergy medication (11% vs 4%) in the three bag protocol compared to the two bag protocol. However the definition of anaphylactoid reaction is not stated clearly and there is a risk for bias and misreporting as the data for the three-bag control group were collected retrospectively while the data for the two-bag group was collected prospectively. More importantly, even if the rate of adverse reactions is truly lower in the two-bag protocol, this is not a sufficient reason to abandon the three-bag protocol. Anaphylactoid reactions or antiallergy medication administration rarely change care plans, length of stay or clinical outcomes. Finally, the time to reaction in Table 2 was analyzed on a log scale. Log transformation helps normalize widely spread out data. While it serves no purpose with events ranging from 1 to 4 h, the use of log analysis may be concerning for incongruent or unreported results. In conclusion, this paper is underpowered both for safety and efficacy, included patients with low risk ingestions and suffers from methodological limitations. Most importantly this paper should not be used to change practice until it can be proved to be safe for patients with acetaminophen concentrations well above the Rumack Matthew line of 993lmol/L (200mcg/mL) at 4 h post ingestion. Disclosure statement