# Situation: A nurse works on the pediatric ward of a tertiary hospital, where children weighing 8 to 30 kg receive most of their medications from the nursing staff. The unit is reviewing its medication safety practices. A 15-kg child with fever has this order: paracetamol (acetaminophen) 200 mg orally every 4 hours, around the clock. The child receives no other paracetamol-containing product. The ward reference gives a usual dose of 10–15 mg/kg per dose and a maximum of 75 mg/kg/day. What should the nurse conclude?

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A nurse works on the pediatric ward of a tertiary hospital, where children weighing 8 to 30 kg receive most of their medications from the nursing staff. The unit is reviewing its medication safety practices.

A 15-kg child with fever has this order: paracetamol (acetaminophen) 200 mg orally every 4 hours, around the clock. The child receives no other paracetamol-containing product. The ward reference gives a usual dose of 10–15 mg/kg per dose and a maximum of 75 mg/kg/day. What should the nurse conclude?

## 보기

1. Safe; six doses a day give 1,200 mg, below the 4,000-mg daily limit
2. Safe; each 200-mg dose is within the 150–225 mg range per dose
3. Unsafe; each 200-mg dose is above the 150-mg maximum single dose
4. Unsafe; six doses a day give 1,200 mg, above the 1,125-mg daily limit **✔ 정답**

**정답: 4**

## 해설

The per-dose range for 15 kg is 10–15 mg/kg, or 150–225 mg, so a 200-mg dose (about 13.3 mg/kg) is acceptable. Given every 4 hours around the clock, the child receives 6 doses, or 1,200 mg (80 mg/kg) a day, but the maximum is 75 mg/kg/day × 15 kg = 1,125 mg. The nurse holds the order at that frequency and clarifies it with the prescriber.

## 심화 해설

Clinical calculation and safety reasoning

For a 15 kg child, the ward reference gives 10–15 mg/kg per dose. The per-dose range is therefore 150–225 mg. A single 200 mg order falls inside that range, at approximately 13.3 mg/kg, so the individual dose is not the problem.

The safety concern comes from the frequency. “Every 4 hours around the clock” means 6 doses in 24 hours. The total daily amount is 200 mg × 6 = 1,200 mg, which equals 80 mg/kg/day. The ward reference caps the total at 75 mg/kg/day, or 1,125 mg for this child. The order is unsafe because the daily total exceeds the weight-based maximum, even though each individual dose is acceptable.

Key point! In pediatric medication safety, both the single dose and the 24-hour total must be checked separately. A dose that is safe once can become hepatotoxic when repeated too frequently.

Watch out! Option 1 uses a 4,000 mg daily limit, but that is an adult ceiling. Pediatric acetaminophen limits are weight-based, not a fixed milligram number.

Acetaminophen toxicity is primarily hepatic. The liver metabolizes acetaminophen through glucuronidation and sulfation, but when those pathways are saturated, a larger proportion is oxidized by CYP2E1 into the toxic intermediate N-acetyl-p-benzoquinone imine (NAPQI). NAPQI is normally conjugated with glutathione and excreted, but repeated supratherapeutic dosing depletes glutathione stores. Unconjugated NAPQI then binds to hepatocyte proteins and causes centrilobular necrosis. In children, the risk is compounded by variable hepatic maturation and lower glycogen reserves during illness, which can reduce glutathione availability. This is why daily maximums in pediatric references are conservative and strictly weight-based.

The audit by McArtney and Atkinson highlights that local pediatric guidelines intentionally use weight-based maximums to prevent inadvertent overdosing, particularly when prescribers apply adult habits to children [1]. Their recommended oral maximum of 90 mg/kg/day in one perioperative guideline is context-specific, but the principle is identical: the ceiling is derived from body weight, not a universal milligram figure.

Roumeliotis et al. found that acetaminophen dosing errors are common in critically ill children and that exceeding the daily maximum recommendation is a measurable form of drug-associated harm . Their work underscores that the daily total, not just the individual dose, is the critical safety variable in pediatric acetaminophen administration. Even short-term errors above the daily maximum have been evaluated for hepatic injury, reinforcing that nurses must calculate the 24-hour exposure before giving any scheduled antipyretic .

In this scenario, the correct nursing action is to recognize the daily total of 1,200 mg exceeds the 1,125 mg maximum, hold the order at that frequency, and clarify with the prescriber. The prescriber may adjust the interval, reduce the per-dose amount, or choose an alternative antipyretic. The nurse does not simply give the medication because the single dose “looks fine.”

Key point! When verifying pediatric acetaminophen orders, always calculate both mg/kg per dose and mg/kg per day. The order is safe only when both values fall within the reference ranges.
References (research sources)

- [1]AUDIT OF PARACETAMOL PRESCRIPTIONS IN PAEDIATRIC SURGICAL PATIENTS.Research articleMcArtney R, Atkinson A (2016) · DOI: 10.1136/archdischild-2016-311535.39

## 임상 시나리오

Pediatric Acetaminophen Double-CheckSingle dose vs. 24-hour total
For a 15 kg child, the per-dose range is 150–225 mg (10–15 mg/kg), so a single 200 mg dose is acceptable. However, around-the-clock dosing every 4 hours gives 6 doses, totaling 1,200 mg/day (80 mg/kg/day), which exceeds the weight-based maximum of 75 mg/kg/day (1,125 mg).

In pediatric medication safety, always verify both the individual dose and the total daily dose independently. A single dose that is safe can become hepatotoxic when repeated too frequently.

CautionDo not apply the adult 4,000 mg daily ceiling to children. Pediatric acetaminophen limits are weight-based, not a fixed milligram number. Hold the order at that frequency and clarify with the prescriber.

## 핵심 개념

- **weight-based dosing** — Calculating medication doses using the patient's body weight in kilograms to ensure safe and effective drug levels, especially in pediatrics.
- **hepatotoxicity** — Liver damage caused by a drug or substance; acetaminophen overdose depletes glutathione and leads to hepatocyte necrosis via the toxic metabolite NAPQI.
- **around the clock** — A dosing frequency meaning the medication is given continuously over 24 hours, such as every 4 hours resulting in 6 doses per day.
- **maximum daily dose** — The highest total amount of a drug that can be safely given in 24 hours, often expressed as mg/kg/day in pediatric patients.
- **NAPQI** — N-acetyl-p-benzoquinone imine, the toxic metabolite of acetaminophen produced by CYP2E1 oxidation that causes liver injury when glutathione is depleted.

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