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Harris TD, Farrar JE, Byerly S, Filiberto DM, Dickerson RN. Evaluation of a Novel Enteral Phosphorus Therapy with Enteral Nutrition during a National Intravenous Sodium Phosphate Shortage. Nutrients 2024; 16:1394. [PMID: 38732640 PMCID: PMC11085910 DOI: 10.3390/nu16091394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024] Open
Abstract
The purpose of this study was to evaluate the efficacy and safety of intragastric administration of small volumes of sodium enema solution containing phosphorus as phosphorus replacement therapy in critically ill patients with traumatic injuries who required continuous enteral nutrition. Adult patients (>17 years of age) who had a serum phosphorus concentration <3 mg/dL (0.97 mmol/L) were evaluated. Patients with a serum creatinine concentration >1.4 mg/dL (124 µmol/L) were excluded. Patients were given 20 mL of saline enema solution intragastrically, containing 34 mmol of phosphorus and mixed in 240 mL water. A total of 55% and 73% of patients who received one (n = 22) or two doses (n = 11) had an improvement in the serum phosphorus concentration, respectively. The serum phosphorus concentration increased from 2.5 [2.1, 2.8] mg/dL (0.81 [0.69, 0.90] mmol/L) to 2.9 [2.2, 3.0] mg/dL (0.94 [0.71, 0.97 mmol/L) for those who received two doses (p = 0.222). Excluding two patients with a marked decline in serum phosphorus by 1.3 mg/dL (0.32 mmol/L) resulted in an increase in the serum phosphorus concentration from 2.3 [2.0, 2.8] mg/dL (0.74 [0.65, 0.90] mmol/L) to 2.9 [2.5, 3.2] mg/dL (0.94 [0.81, 1.03] mmol/L; n = 9; p = 0.012). No significant adverse effects were noted. Our data indicated that intragastric phosphate administration using a small volume of saline enema solution improved the serum phosphorus concentrations in most patients.
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Affiliation(s)
- Tinia D. Harris
- Department of Pharmacy, Regional One Health, Memphis, TN 38103, USA
| | - Julie E. Farrar
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Saskya Byerly
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Dina M. Filiberto
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Roland N. Dickerson
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN 38163, USA
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2
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Stratmann K, Hentschel V, Zeuzem S, Blumenstein I, Klaus J. [Iron supplementation in patients with chronic inflammatory bowel disease: recommendations for a practical approach]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024. [PMID: 38657618 DOI: 10.1055/a-2274-1610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Iron deficiency is the predominant cause of anemia. Iron deficiency anemia plays a major role, especially in patients with inflammatory bowel disease (IBD), and is the most common extraintestinal manifestation and IBD-associated systemic complication. The presence of anemia leads to a reduction in quality of life in patients with IBD associated with limitations in physical, emotional, and cognitive function. In addition, it is associated with an increased hospitalization rate. For this reason, iron supplementation is of particular importance. Oral and intravenous iron supplements are used to treat iron deficiency. Due to the lack of absorption and gastrointestinal side effects of oral substitution, intravenous supplementation is becoming increasingly important. However, there are still certain concerns about intravenous administration.With the help of this review, we want to address the topic of iron substitution in patients with IBD, summarize current guideline recommendations, and provide a practical approach.
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Affiliation(s)
- Katharina Stratmann
- Universitätsklinikum, Medizinische Klinik 1, Goethe-Universität Frankfurt, Frankfurt am Main, Germany
| | | | - Stefan Zeuzem
- Universitätsklinikum, Medizinische Klinik 1, Goethe-Universität Frankfurt, Frankfurt am Main, Germany
| | - Irina Blumenstein
- Universitätsklinikum, Medizinische Klinik 1, Goethe-Universität Frankfurt, Frankfurt am Main, Germany
| | - Jochen Klaus
- Klinik für Innere Medizin 1, Universitätsklinikum Ulm, Ulm, Germany
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3
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Lair CS, Brown LS, Edwards A, Jacob T, Brion LP, Jaleel M. Quality improvement project in a neonatal intensive care unit reduced the prevalence and duration of hypophosphatemia with significant and sustainable results. Nutr Clin Pract 2023; 38:1379-1391. [PMID: 37042685 DOI: 10.1002/ncp.10986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/15/2023] [Accepted: 03/04/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Hypophosphatemia is associated with prolonged mechanical ventilation and may affect growth, bone mineralization, nephrocalcinosis, and mortality in preterm infants. Optimal nutrition practices may decrease risk for hypophosphatemia and improve outcome. METHODS A quality improvement project was established to improve parenteral and enteral phosphorus intake with the goal to decrease prevalence and duration of hypophosphatemia in the first 14 days in infants <32 weeks' gestation. RESULTS Among 406 preterm infants, the prevalence of moderate hypophosphatemia decreased from 44% to 19% (P < 0.01) over 4 years. The median duration of moderate hypophosphatemia decreased from 72 h (48-128) to 24 (24-53) (P < 0.01). Daily intakes of parenteral calcium and phosphorus on the fourth day of life increased from 1.5 to 2.5 mEq/kg/day (P < 0.01) and 0.6 to 1.3 mmol/kg/day (P < 0.01), respectively. The median postnatal age of first serum phosphorus concentration assessment decreased from 53 h (41-64) to 32 (24-40) (P < 0.01). CONCLUSION During this quality improvement project, reduced prevalence and duration of hypophosphatemia in infants <32 weeks' gestation in the first 14 days of life was achieved through the optimization of parenteral and enteral phosphorus intake and improved response to acute hypophosphatemia.
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Affiliation(s)
- Cheryl S Lair
- Department of Clinical Nutrition, Parkland Health & Hospital System, Dallas, Texas, USA
| | - L Steven Brown
- Department of Clinical Nutrition, Parkland Health & Hospital System, Dallas, Texas, USA
| | - Audrey Edwards
- Department of Clinical Nutrition, Parkland Health & Hospital System, Dallas, Texas, USA
| | - Theresa Jacob
- Department of Clinical Nutrition, Parkland Health & Hospital System, Dallas, Texas, USA
| | - Luc P Brion
- Division of Neonatal-Perinatal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Mambarambath Jaleel
- Division of Neonatal-Perinatal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
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4
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Hakeam H, Alsemari M, Mohamed G, Alshahrani A, Islami M. The Rate of Discontinuing Ready-to-Use Multi-Chamber Bag Parenteral Nutrition Secondary to High Serum Electrolyte Levels. Hosp Pharm 2023; 58:263-271. [PMID: 37216070 PMCID: PMC10192983 DOI: 10.1177/00185787221133711] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Background: Multi-chamber bag with electrolytes (MCB-E) parenteral nutrition (PN) formulations are gaining acceptance for nutritional support for safety and economic advantages. However, their use is hampered by serum electrolyte abnormalities. No data exist regarding MCB-E PN interruption due to high serum electrolyte levels. We assessed the rate of MCB-E PN discontinuation in surgical patients secondary to persistently high serum electrolyte levels. Methods: This prospective, cohort study included surgical patients (aged ≥18 years) who received MCB-E PN at King Faisal Specialist Hospital and Research Centre-Riyadh, from February 28, 2020, until August 30, 2021. Patients were followed for 30-day for the discontinuation of MCB-E PN secondary to persistent hyperphosphatemia, hyperkalemia, hypermagnesemia, or hypernatremia for two consecutive days. The association of discontinuing MCB-E PN with various factors was assessed using univariable and multivariable Poisson regression analysis. Results: Seventy-two patients were enrolled in the study, 55 (76.4%) completed MCB-E PN, whereas 17 (23.6%) patients discontinued MCB-E PN due to a persistent hyperphosphatemia (n = 13, 18%) and persistent hyperkalemia (n = 4, 5.5%). Hyperphosphatemia and hyperkalemia were observed at a median of 9 (IQR 6-15) days and 9.5 (IQR 7-12) days of MCB-E PN support, respectively. According to adjusted multivariable analysis, developing an episode of hyperphosphatemia or hyperkalemia was associated with MCB-E PN discontinuation (RR 6.62, 1.95-22.49; P = .002) and (RR 4.73, 1.30-17.24; P = .018), respectively. Conclusion: In surgical patients receiving short-term MCB-E PN, developing hyperphosphatemia was the most frequent high electrolyte abnormality assocaited with MCB-E PN discontinuation, followed by hyperkalemia.
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Affiliation(s)
- Hakeam Hakeam
- Pharmaceutical Care Division, King
Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi
Arabia
| | - Muhannad Alsemari
- Department of Surgery, King Faisal
Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gamal Mohamed
- Department of Biostatistics,
Epidemiology and Scientific Computing, King Faisal Specialist Hospital and Research
Centre, Riyadh, Saudi Arabia
| | - Asma Alshahrani
- Department of Biostatistics,
Epidemiology and Scientific Computing, King Faisal Specialist Hospital and Research
Centre, Riyadh, Saudi Arabia
| | - Muna Islami
- Pharmacy Services, King Faisal
Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
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Dock-Nascimento DB, Ribeiro AC, Silva Junior JM, de Aguilar-Nascimento JE. Impact of Nutritional Management on Survival of Critically Ill Malnourished Patients with Refeeding Hypophosphatemia. Arch Med Res 2023; 54:231-238. [PMID: 36805190 DOI: 10.1016/j.arcmed.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Early nutritional therapy may aggravate hypophosphatemia in critically ill patients. AIM To investigate the influence of the type nutritional therapy on the survival of critically-ill malnourished patients at refeeding hypophosphatemia risk. METHODS Retrospective cohort study including malnourished, critically-ill adults, admitted from June 2014-December 2017 in an intensive care unit (ICU) at a tertiary hospital. Refeeding hypophosphatemia risk was defined as low serum phosphorus levels (<2.5 mg/dL) seen at two timepoints: before the initiation and at day 4 of the nutritional therapy. Patients receiving enteral nutrition (EN) were compared with those receiving supplemental parenteral nutrition (SPN-EN plus parenteral nutrition). Primary outcome was 60 d survival. Secondary endpoint was the incidence of refeeding hypophosphatemia risk. RESULTS We included 468-321 patients (68.6%) received EN and 147 (31.4%) received SPN. The mortality rate was 36.3% (n = 170). Refeeding hypophosphatemia risk was found in 116 (24.8%) patients before and in 177 (37.8%) at day 4 of nutritional therapy. The 60 d mean survival probability was greater for patients receiving SPN both before (42.4 vs. 22.4%, p = 0.005) and at day 4 (37.4 vs. 25.8%, p = 0.014) vs. patients receiving EN at the same timepoints. Cox regression showed a hazard ratio of 3.3 and 2.4 for patients at refeeding hypophosphatemia risk before and at day 4 of EN, respectively, compared to the SPN group at the same timepoints. CONCLUSION Refeeding hypophosphatemia risk was frequent in malnourished ICU patients and the survival for patients receiving SPN seemed associated with better survival than EN only.
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Affiliation(s)
| | - Amanda Coelho Ribeiro
- Postgraduate Program in Health Sciences, Federal University of Mato Grosso Cuiabá, Brazil
| | - João Manoel Silva Junior
- Postgraduate Program in Anesthesiology of University of São Paulo, Brazil; Anesthesiology Department of Hospital do Servidor Publico Estadual, São Paulo, Brazil
| | - José Eduardo de Aguilar-Nascimento
- Postgraduate Program in Health Sciences, Federal University of Mato Grosso Cuiabá, Brazil; University Center of Várzea Grande Medical School, Cuiabá, Brazil.
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Wang R, He M, Kang Y. Hypophosphatemia at Admission is Associated with Increased Mortality in COVID-19 Patients. Int J Gen Med 2021; 14:5313-5322. [PMID: 34526806 PMCID: PMC8435477 DOI: 10.2147/ijgm.s319717] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/18/2021] [Indexed: 02/05/2023] Open
Abstract
Background Electrolyte disturbances are commonly observed in patients with coronavirus disease 2019 (COVID-19) and associated with outcome in these patients. Our study was designed to examine whether hypophosphatemia is associated with mortality in COVID-19 patients. Methods Patients diagnosed with COVID-19 and hospitalized in Renmin Hospital of Wuhan University between January 30 and February 24, 2020 were included in this study. Patients were divided into two groups, a hypophosphatemia group and a non-hypophosphatemia group, based on a serum phosphate level of 0.8 mmol/L. Logistic regression was performed to analyze the relationship between hypophosphatemia and mortality. A locally weighted scatterplot smoothing (LOWESS) curve was plotted to show the detailed association between mortality rate and serum phosphate level. A Kaplan–Meier survival curve was drawn to compare the difference in cumulative survival between the two groups. Results Hypophosphatemia at admission occurred in 33 patients, with an incidence of 7.6%. The hypophosphatemia group had a significantly higher incidence of respiratory failure (54.5% vs 32.6%, p=0.013) and mortality (57.6% vs 15.2%, p<0.001). Multivariate logistic regression indicated that age (OR=1.059, p<0.001), oxygen saturation (OR=0.733, p<0.001), white blood cells (OR=1.428, p<0.001), lymphocytes (OR=0.075, p<0.001) and hypophosphatemia (OR=3.636, p=0.015) were independently associated with mortality in the included patients. The hypophosphatemia group had significantly shorter survival than the non-hypophosphatemia group (p<0.001). Conclusion Hypophosphatemia at admission is associated with increased mortality in COVID-19 patients. More attention and medical care should be given to COVID-19 patients with hypophosphatemia at admission.
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Affiliation(s)
- Ruoran Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Min He
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, People's Republic of China.,COVID19 Medical Team (Hubei) of West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, People's Republic of China.,COVID19 Medical Team (Hubei) of West China Hospital, Sichuan University, Chengdu, People's Republic of China
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7
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Augmented Renal Clearance Following Traumatic Injury in Critically Ill Patients Requiring Nutrition Therapy. Nutrients 2021; 13:nu13051681. [PMID: 34063391 PMCID: PMC8156106 DOI: 10.3390/nu13051681] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 11/23/2022] Open
Abstract
The intent of this study was to ascertain the prevalence of augmented renal clearance (ARC) in patients with traumatic injuries who require nutrition therapy and identify factors associated with ARC. Adult patients admitted to the trauma intensive care unit from January 2015 to September 2016 who received enteral or parenteral nutrition therapy and had a 24 h urine collection within 4 to 14 days after injury were retrospectively evaluated. Patients with a serum creatinine concentration > 1.5 mg/dL, required dialysis, or had an incomplete urine collection were excluded. ARC was defined as a measured creatinine clearance > 149 mL/min/1.73 m2. Two hundred and three patients were evaluated. One hundred and two (50%) exhibited ARC. A greater proportion of patients with ARC were male (86% vs. 67%; p = 0.004), had traumatic brain injury (33% vs. 9%; p = 0.001), a higher injury severity score (30 ± 11 vs. 26 ± 12; p = 0.015), were younger (36 ± 15 vs. 54 ± 17 years; p = 0.001), had a lower serum creatinine concentration (0.7 ± 2 vs. 0.9 ± 0.2 mg/dL; p = 0.001) and were more catabolic (nitrogen balance of −10.8 ± 13.0 vs. −6.2 ± 9.2 g/d; p = 0.004). The multivariate analysis revealed African American race and protein intake were also associated with ARC. Half of critically ill patients with traumatic injuries experience ARC. Patients with multiple risk factors for ARC should be closely evaluated for dosing of renally-eliminated electrolytes, nutrients, and medications.
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8
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Ribeiro AC, Dock-Nascimento DB, Silva JM, Caporossi C, Aguilar-Nascimento JED. Hypophosphatemia and risk of refeeding syndrome in critically ill patients before and after nutritional therapy. ACTA ACUST UNITED AC 2020; 66:1241-1246. [PMID: 33027452 DOI: 10.1590/1806-9282.66.9.1241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 02/26/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To investigate the prevalence of hypophosphatemia as a marker of refeeding syndrome (RFS) before and after the start of nutritional therapy (NT) in critically ill patients. METHODS Retrospective cohort study including 917 adult patients admitted at the intensive care unit (ICU) of a tertiary hospital in Cuiabá-MT/Brasil. We assessed the frequency of hypophosphatemia (phosphorus <2.5mg/dl) as a risk marker for RFS. Serum phosphorus levels were measured and compared at admission (P1) and after the start of NT (P2). RESULTS We observed a significant increase (36.3%) of hypophosphatemia and, consequently, a greater risk of RFS from P1 to P2 (25.6 vs 34.9%; p<0.001). After the start of NT, malnourished patients had a greater fall of serum phosphorus. Patients receiving NT had an approximately 1.5 times greater risk of developing RFS (OR= 1.44 95%CI 1.10-1,89; p= 0.01) when compared to those who received an oral diet. Parenteral nutrition was more associated with hypophosphatemia than either enteral nutrition (p=0,001) or parenteral nutrition supplemented with enteral nutrition (p=0,002). CONCLUSION The frequency of critically ill patients with hypophosphatemia and at risk for RFS on admission is high and this risk increases after the start of NT, especially in malnourished patients and those receiving parenteral nutrition.
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Affiliation(s)
- Amanda Coelho Ribeiro
- Nutricionista, Mestre em Ciências da Saúde pelo Programa de Pós-Graduação em Ciências da Saúde da Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil
| | - Diana Borges Dock-Nascimento
- Nutricionista, Professor Doutor Associado II, Faculdade de Nutrição da UFMT, Departamento de Alimentos e Nutrição em Cuiabá-MT. Professor orientador do Programa de Pós-Graduação em Ciências da Saúde da Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil
| | - João Manoel Silva
- Médico, Professor orientador do Programa de Pós-Graduação em Anestesiologia da Universidade de São Paulo, São Paulo, SP, Brasil.,Componente do corpo clínico do Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
| | - Cervantes Caporossi
- Médico, Professor Doutor do Programa de Pós-Graduação em Ciências da Saúde da Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil
| | - José Eduardo de Aguilar-Nascimento
- Médico, Professor Doutor do Programa de Pós-Graduação em Ciências da Saúde da Universidade Federal de Mato Grosso, Cuiabá, MT, Brasil.,Diretor do Curso de Medicina do Centro Universitário de Várzea Grande (Univag), Várzea Grande, MT, Brasil
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9
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Reintam Blaser A, Gunst J, Ichai C, Casaer MP, Benstoem C, Besch G, Dauger S, Fruhwald SM, Hiesmayr M, Joannes-Boyau O, Malbrain MLNG, Perez MH, Schaller SJ, de Man A, Starkopf J, Tamme K, Wernerman J, Berger MM. Hypophosphatemia in critically ill adults and children - A systematic review. Clin Nutr 2020; 40:1744-1754. [PMID: 33268142 DOI: 10.1016/j.clnu.2020.09.045] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Phosphate is the main intracellular anion essential for numerous biological processes. Symptoms of hypophosphatemia are non-specific, yet potentially life-threatening. This systematic review process was initiated to gain a global insight into hypophosphatemia, associated morbidity and treatments. METHODS A systematic review was conducted (PROSPERO CRD42020163191). Nine clinically relevant questions were generated, seven for adult and two for pediatric critically ill patients, and prevalence of hypophosphatemia was assessed in both groups. We identified trials through systematic searches of Medline, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. Quality assessment was performed using the Cochrane risk of bias tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies. RESULTS For all research questions, we identified 2727 titles in total, assessed 399 full texts, and retained 82 full texts for evidence synthesis, with 20 of them identified for several research questions. Only 3 randomized controlled trials were identified with two of them published only in abstract form, as well as 28 prospective and 31 retrospective studies, and 20 case reports. Relevant risk of bias regarding selection and comparability was identified for most of the studies. No meta-analysis could be performed. The prevalence of hypophosphatemia varied substantially in critically ill adults and children, but no study assessed consecutive admissions to intensive care. In both critically ill adults and children, several studies report that hypophosphatemia is associated with worse outcome (prolonged length of stay and the need for respiratory support, and higher mortality). However, there was insufficient evidence regarding the optimal threshold upon which hypophosphatemia becomes critical and requires treatment. We found no studies regarding the optimal frequency of phosphate measurements, and regarding the time window to correct hypophosphatemia. In adults, nutrient restriction on top of phosphate repletion in patients with refeeding syndrome may improve survival, although evidence is weak. CONCLUSIONS Evidence on the definition, outcome and treatment of clinically relevant hypophosphatemia in critically ill adults and children is scarce and does not allow answering clinically relevant questions. High quality clinical research is crucial for the development of respective guidelines.
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Affiliation(s)
- Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland.
| | - Jan Gunst
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium.
| | - Carole Ichai
- Mixed Intensive Care Unit, Université Côte d'Azur, Nice, France.
| | - Michael P Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium.
| | - Carina Benstoem
- Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, Aachen, Germany.
| | - Guillaume Besch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France.
| | - Stéphane Dauger
- Pediatric Intensive Care Unit, Robert-Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Sonja M Fruhwald
- Department of Anesthesiology and Intensive Care Medicine, Division of Anesthesiology for Cardiovascular Surgery and Intensive Care Medicine, Medical University of Graz, Graz, Austria.
| | - Michael Hiesmayr
- Cardiac Thoracic Vascular Anaesthesia and Intensive Care, Medical University Vienna, Waehringerguertel 18-20, 1090 Vienna, Austria.
| | - Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation SUD, Hôpital Magellan, CHU de Bordeaux, Bordeaux, France.
| | - Manu L N G Malbrain
- Department Intensive Care Medicine, University Hospital Brussel (UZB), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Jette, Brussels, Belgium.
| | - Maria-Helena Perez
- Paediatric Intensive Care Unit, Department of Paediatrics, Division Women-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland.
| | - Stefan J Schaller
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine, Berlin, Germany.
| | | | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, University of Tartu, Estonia.
| | - Kadri Tamme
- Department of Anaesthesiology and Intensive Care, Tartu University Hospital, University of Tartu, Estonia.
| | - Jan Wernerman
- Department of Perioperative Medicine, Karolinska University Hospital Huddinge, CLINTEC Karolinska Institutet, Stockholm, Sweden.
| | - Mette M Berger
- Service of Adult Intensive care & Burns, Lausanne University Hospital, Lausanne, Switzerland.
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10
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García Martín A, Varsavsky M, Cortés Berdonces M, Ávila Rubio V, Alhambra Expósito MR, Novo Rodríguez C, Rozas Moreno P, Romero Muñoz M, Jódar Gimeno E, Rodríguez Ortega P, Muñoz Torres M. Phosphate disorders and clinical management of hypophosphatemia and hyperphosphatemia. ACTA ACUST UNITED AC 2019; 67:205-215. [PMID: 31501071 DOI: 10.1016/j.endinu.2019.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 05/20/2019] [Accepted: 06/03/2019] [Indexed: 12/13/2022]
Abstract
Serum phosphorus levels range from 2.5 and 4.5mg/dL (0.81-1.45 mmol/L) in adults, with higher levels in childhood, adolescence, and pregnancy. Intracellular phosphate is involved in intermediary metabolism and other essential cell functions, while extracellular phosphate is essential for bone matrix mineralization. Plasma phosphorus levels are maintained within a narrow range by regulation of intestinal absorption, redistribution, and renal tubular absorption of the mineral. Hypophosphatemia and hyperphosphatemia are common clinical situations, although changes are most often mild and oligosymptomatic. However, acute and severe conditions that require specific treatment may occur. In this document, members of the Mineral and Bone Metabolism Working Group of the Spanish Society of Endocrinology and Nutrition review phosphate disorders and provide algorithms for adequate clinical management of hypophosphatemia and hyperphosphatemia.
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Affiliation(s)
- Antonia García Martín
- Unidad de Gestión Clínica (UGC) de Endocrinología y Nutrición, Hospital Universitario San Cecilio, Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Granada, España.
| | - Mariela Varsavsky
- Servició de Endocrinología, Metabolismo y Medicina Nuclear, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - María Cortés Berdonces
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Ruber Juan Bravo, Madrid, España
| | - Verónica Ávila Rubio
- Unidad de Gestión Clínica (UGC) de Endocrinología y Nutrición, Hospital Universitario San Cecilio, Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Granada, España
| | - María Rosa Alhambra Expósito
- Unidad de Gestión Clínica (UGC) de Endocrinología y Nutrición, Hospital Universitario Reina Sofía, Córdoba, España
| | | | - Pedro Rozas Moreno
- Sección de Endocrinología y Nutrición, Hospital General Universitario de Ciudad Real, Ciudad Real, España
| | - Manuel Romero Muñoz
- Unidad de Endocrinología y Nutrición, Hospital General Universitario Rafael Méndez, Lorca, Murcia, España
| | - Esteban Jódar Gimeno
- Departamento de Endocrinología y Nutrición Clínica, Hospital Universitario Quirón Salud Madrid y Hospital Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, España
| | | | - Manuel Muñoz Torres
- Unidad de Gestión Clínica (UGC) de Endocrinología y Nutrición, Hospital Universitario San Cecilio, Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Granada, España; Departamento de Medicina, Universidad de Granada, Granada, España
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11
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Federspiel CK, Itenov TS, Thormar K, Liu KD, Bestle MH. Hypophosphatemia and duration of respiratory failure and mortality in critically ill patients. Acta Anaesthesiol Scand 2018; 62:1098-1104. [PMID: 29687440 DOI: 10.1111/aas.13136] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 03/13/2018] [Accepted: 03/30/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hypophosphatemia has been associated with prolonged duration of respiratory failure and increased mortality in critically ill patients, but there is very limited evidence supporting the negative effects of low phosphate. We examined the association between hypophosphatemia at ICU admission and time to successful weaning and 28-day mortality. METHODS This was a cohort study that included all mechanically ventilated adult patients admitted to the ICU in 2013 at Nordsjællands Hospital. Hypophosphatemia was defined as a serum level below 0.80 mmol/L. Multivariate Cox-regression was used to evaluate the effect of hypophosphatemia on mechanical ventilation and 28-day mortality. Multiple imputation was used to adjust for missing values. RESULTS A total of patients were admitted during the study period, of whom 190 were eligible. 122 (64.2%) had serum phosphate levels measured during the first 24 hours of admission, of whom 25 (20.5%) were found to be hypophosphatemic. About 74% of patients were successfully weaned from the ventilator within 28 days. Hypophosphatemia was not associated with this outcome (HR: 0.56; 95% CI: 0.30-1.04; P = .067). All-cause 28-day mortality was 32.6%. Hypophosphatemia was also not associated with 28-day mortality (HR: 1.64; 95% CI: 0.65-4.17; P = .447). Similar results were present in supplementary analysis where missing data were included by means of multiple imputation. CONCLUSION Hypophosphatemia at ICU admission was not associated with prolonged respiratory failure nor mortality. Further studies are warranted, where phosphate is measured systematically on all patients to elucidate the effect of low phosphate on relevant outcomes.
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Affiliation(s)
- C K Federspiel
- Department of Anaesthesiology, Nordsjællands Hospital, Hillerød, University of Copenhagen, Hillerød, Denmark
| | - T S Itenov
- Department of Anaesthesiology, Nordsjællands Hospital, Hillerød, University of Copenhagen, Hillerød, Denmark
| | - K Thormar
- Department of Anaesthesiology, Landspítali Háskólasjúkrahús, Reykjavík, Iceland
| | - K D Liu
- Departments of Medicine and Anesthesia, University of California, San Francisco, CA, USA
| | - M H Bestle
- Department of Anaesthesiology, Nordsjællands Hospital, Hillerød, University of Copenhagen, Hillerød, Denmark
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12
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Kaderbay A, Atallah I, Fontaine E, Chobert-Bakouline M, Schmitt S, Mitariu P, Righini CA. Malnutrition and refeeding syndrome prevention in head and neck cancer patients: from theory to clinical application. Eur Arch Otorhinolaryngol 2018; 275:1049-1058. [PMID: 29569135 DOI: 10.1007/s00405-018-4935-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/13/2018] [Indexed: 12/23/2022]
Abstract
PURPOSE The goal of this review is to raise awareness about refeeding syndrome (RFS) and to give a comprehensive presentation of recent guidelines and latest scientific data about nutritional management among head and neck cancer (HNC) patients while focusing on RFS prevention. METHODS A review of literature for nutritional assessment and RFS management was conducted. Electronic searches of Medline, Cochrane, PubMed and Embase databases for articles published in peer-reviewed journals were conducted from February to September 2017 using the keywords: "nutrition assessment", "head and neck cancer", "refeeding syndrome" and "guidelines". Articles, reviews, book references as well as national and international guidelines in English and French were included. RESULTS The prevalence of malnutrition is high in HNC patients and a large number of them will need artificial nutritional support or refeeding intervention. RFS is characterized by fluid and electrolyte imbalance associated with clinical manifestations induced by rapid refeeding after a period of malnutrition or starvation. Regarding risk factors for malnutrition and RFS, HNC patients are particularly vulnerable. However, RFS remains unrecognized among head and neck surgeons and medical teams. Practical data are summarized to help organizing nutritional assessment and refeeding interventions. It also summarizes preventive measures to reduce RFS incidence and morbidity in HNC population. CONCLUSION Nutritional assessment and early refeeding interventions are crucial for HNC patients care. As prevention is the key for RFS management, early identification of patients with high risks is crucial and successful nutritional management requires a multidisciplinary approach.
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Affiliation(s)
- Akil Kaderbay
- Otolaryngology Department, Grenoble Alpes University Hospital, Grenoble, France.
- Grenoble Alpes University, Grenoble, France.
- UGA/Inserm U1205, Braintech Lab, Grenoble, France.
- Otolaryngoloy Department of Grenoble Alpes University Hospital, Hôpital Nord Michallon, CS 10217, 38043, Grenoble Cedex 9, France.
| | - Ihab Atallah
- Otolaryngology Department, Grenoble Alpes University Hospital, Grenoble, France
- Grenoble Alpes University, Grenoble, France
- UGA/UMR/CNRS 5309/Inserm 1209, Institut Albert Bonniot, Grenoble, France
- Otolaryngoloy Department of Grenoble Alpes University Hospital, Hôpital Nord Michallon, CS 10217, 38043, Grenoble Cedex 9, France
| | - Eric Fontaine
- Nutrition Department, Grenoble Alpes University Hospital, Grenoble, France
- UGA/Inserm U1055, Grenoble, France
| | | | - Stephanie Schmitt
- Otolaryngology Department, Grenoble Alpes University Hospital, Grenoble, France
| | | | - Christian Adrien Righini
- Otolaryngology Department, Grenoble Alpes University Hospital, Grenoble, France
- Grenoble Alpes University, Grenoble, France
- UGA/UMR/CNRS 5309/Inserm 1209, Institut Albert Bonniot, Grenoble, France
- Otolaryngoloy Department of Grenoble Alpes University Hospital, Hôpital Nord Michallon, CS 10217, 38043, Grenoble Cedex 9, France
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13
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Bissell BD, Davis JE, Flannery AH, Adkins DA, Thompson Bastin ML. Aggressive Treatment of Life-Threatening Hypophosphatemia During Recovery From Fulminant Hepatic Failure: A Case Report. J Intensive Care Med 2017; 33:375-379. [PMID: 29088996 DOI: 10.1177/0885066617738715] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Acute liver failure secondary to acetaminophen overdose can be a life-threatening condition, characterized by severe electrolyte derangements. Hepatocyte regeneration is associated with phosphorous utilization and is a known complication of liver recovery following injury. We report the case of profound, life-threatening hypophosphatemia following recovery from acute fulminant liver failure. As the liver enzymes normalized, serum phosphorous levels plummeted. Our patient required an aggressive, individualized phosphorus replacement regimen, which resulted in a continuous infusion of intravenous (IV) sodium phosphate, titrated to a maximum rate of 30 mmol/h or 0.5 mmol/kg/h. The patient required over 400 mmol of total IV and oral phosphorous over the course of 48 hours. An aggressive approach to phosphorous replacement was done safely and effectively. Traditional replacement protocols are not adequate to sustain patients with this degree of hypophosphatemia. This is the first report to utilize a continuous infusion of phosphate with a maximum reported rate (0.5 mmol/kg/h). Our report summarizes a novel and safe approach for clinicians to maximally support these patients through high-dose, continuous infusion phosphorous administration.
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Affiliation(s)
- Brittany D Bissell
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Jason E Davis
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Alexander H Flannery
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA.,2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - David A Adkins
- 3 Division of Critical Care and Pulmonology, West Virginia University College of Medicine, Morgantown, WV, USA
| | - Melissa L Thompson Bastin
- 1 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA.,2 Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
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14
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Padelli M, Leven C, Sakka M, Plée-Gautier E, Carré JL. [Causes, consequences and treatment of hypophosphatemia: A systematic review]. Presse Med 2017; 46:987-999. [PMID: 29089216 DOI: 10.1016/j.lpm.2017.09.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 08/24/2017] [Accepted: 09/12/2017] [Indexed: 12/16/2022] Open
Abstract
CONTEXT Although hypophosphatemia is usually very seldom, it can reach two to 3% of hospitalized patients and until 28% of intensive care unit patients. Due to the lack of knowledge, clinical practice regarding seeking or treatment of hypophosphatemia is very heterogenous. However its clinical consequences might be heavy. A better knowledge of its causes, physiopathological effects and treatment should lead to a documented and homogenous care of these patients in clinics. OBJECTIVE The aim of our study was a systematic review of littérature, seeking for publications about causes, consequences and treatment of hypophosphatemia. DOCUMENTARY SOURCES (KEYWORDS AND LANGUAGE) A research has been conducted on the Medline database by using the following keywords "phosphorus supplementation", "hypophosphatemia" and ("physiopathology" or "complications"). RESULTS Three mains mechanisms might be responsible for hypophosphatemia: a decrease in digestive absorption, a rise in kidney excretion and a transfer of phosphorus to the intracellular compartment. Denutrition, acid base balance troubles, parenteral nutrition or several drugs are capable of provoking or favouring hypophosphatemia. All these situations are frequently encountered in intensive care unit. Consequences of hypophosphatemia might be serious. Best studied and documented are cardiac and respiratory muscle contractility decrease, sometimes leading to acute cardiac and respiratory failure, cardiac rhythm troubles and cardiac arrest. Hypophosphatemia is frequent during sepsis. It could be responsible for leucocyte dysfunction that might favour or increase sepsis. The treatment of hypophosphatemia is usually simple through a supplementation that quickly restores a regular concentration, with few adverse effects when regularly used. CONCLUSION During at-risk situations, the systematic search for hypophosphatemia and its treatment may limit the occurrence of serious consequences.
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Affiliation(s)
- Maël Padelli
- University hospital of Brest, department of biochemistry and pharmaco-toxicology, 29200 Brest, France.
| | - Cyril Leven
- University hospital of Brest, department of biochemistry and pharmaco-toxicology, 29200 Brest, France
| | - Mehdi Sakka
- University hospital of Brest, department of biochemistry and pharmaco-toxicology, 29200 Brest, France
| | - Emmanuelle Plée-Gautier
- University hospital of Brest, department of biochemistry and pharmaco-toxicology, 29200 Brest, France
| | - Jean-Luc Carré
- University hospital of Brest, department of biochemistry and pharmaco-toxicology, 29200 Brest, France
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15
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Clark SL, Nystrom EM. A Case of Severe, Prolonged, Refractory Hypophosphatemia After Zoledronic Acid Administration. J Pharm Pract 2016; 29:172-6. [DOI: 10.1177/0897190015624050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Zoledronic acid (ZA) administration has been associated with electrolyte abnormalities, including hypocalcemia, hypomagnesemia, hypokalemia, and hypophosphatemia. We describe a case of severe, refractory hypophosphatemia in a patient who received ZA for hypercalcemia of malignancy (HCM). Little data are available that describe the incidence or degree of severity of hypophosphatemia that can occur following ZA administration. In addition, no formal recommendations exist to guide monitoring for or management of electrolyte derangements in the setting of bisphosphonate use. Our patient required daily, high-dose phosphorus replacement beginning day 4 following ZA administration. The average daily dose of phosphorus, including both intravenous and enteral administration, was highest in the first 2 weeks after ZA, averaging 77 mmol/d days 4 through 15, and does not include sources of phosphorus from the patient’s nutrition support. Despite this high amount of supplementation, which was well beyond what meets normal daily requirements and the amount expected to treat “usual” hypophosphatemia, the patient did not achieve sustained normal serum phosphorus levels for over 30 days after ZA. ZA is a favorable option for treating HCM because of its longer duration of action, potent serum calcium-lowering effects, and favorable safety profile. The risk of hypophosphatemia with ZA use is reviewed.
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Affiliation(s)
- Sarah L. Clark
- Department of Pharmacy, Mayo Clinic, Mayo College of Medicine, Rochester, MN, USA
| | - Erin M. Nystrom
- Department of Pharmacy, Mayo Clinic, Mayo College of Medicine, Rochester, MN, USA
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16
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Johnston CT, Maish GO, Minard G, Croce MA, Dickerson RN. Evaluation of an Intravenous Potassium Dosing Algorithm for Hypokalemic Critically Ill Patients. JPEN J Parenter Enteral Nutr 2015; 41:796-804. [PMID: 26304602 DOI: 10.1177/0148607115602885] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The intent of this study was to evaluate the safety and efficacy of an intravenous (IV) potassium (K) dosing algorithm for hypokalemic critically ill trauma patients. METHODS Adult patients, admitted to the trauma intensive care unit from June 2010 to October 2012 and who received IV K therapy according to a standardized dosing algorithm, were retrospectively evaluated. Patients who received IV K during resuscitation or following initiation of nutrition therapy, IV fluids containing >20 mEq/L of potassium, or medications known to alter K homeostasis or those with an arterial pH change >0.1, diarrhea, hypomagnesemia, renal impairment, or morbid obesity were excluded. RESULTS In total, 715 patients were reviewed to obtain 100 evaluable patients. Serum K for patients with mild depletion (serum K, 3.5-3.9 mEq/L, n = 74) remained unchanged at 0.0 ± 0.3 mEq/L ( P = ns) following 46 ± 8 mEq. Serum K increased by 0.4 ± 0.3 mEq/L ( P = .001) following 78 ± 18 mEq during moderate depletion (serum K, 3-3.4 mEq/L). None of the patients experienced hyperkalemia (serum K, >5.2 mEq/L) postinfusion. The presence of traumatic brain injury (TBI) blunted the response to IV K for mild K depletion as only 26% had an increase in serum K compared with 55% of patients without TBI ( P = .025). CONCLUSIONS The Nutrition Support Service-guided IV K dosing algorithm was safe for patients with mild and moderate hypokalemia and efficacious for those with moderate hypokalemia. Further study in patients with severe hypokalemia (serum K, <3 mEq/L) is warranted.
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Affiliation(s)
- Corry T Johnston
- 1 Department of Pharmacy, University of Maryland Baltimore Washington Medical Center, Baltimore, Maryland, USA
| | - George O Maish
- 2 Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Gayle Minard
- 2 Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Martin A Croce
- 2 Department of Surgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Roland N Dickerson
- 3 Department of Clinical Pharmacy, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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17
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Håglin L. Using phosphate supplementation to reverse hypophosphatemia and phosphate depletion in neurological disease and disturbance. Nutr Neurosci 2015; 19:213-23. [DOI: 10.1179/1476830515y.0000000024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Lena Håglin
- Department of Public Health and Clinical Medicine, Sweden
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18
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Pathophysiology, treatment, and prevention of fluid and electrolyte abnormalities during refeeding syndrome. JOURNAL OF INFUSION NURSING 2015; 37:197-202. [PMID: 24694513 DOI: 10.1097/nan.0000000000000038] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Refeeding syndrome may occur after the reintroduction of carbohydrates in chronically malnourished or acutely hypermetabolic patients as a result of a rapid shift to glucose utilization as an energy source. Electrolyte abnormalities of phosphorus, potassium, and magnesium occur, leading to complications of various organ systems, and may result in death. Patients should be screened for risk factors of malnutrition to prevent refeeding syndrome. For those at risk, nutrition should be initiated and slowly advanced toward the patient's goal over several days. Electrolyte disturbances should be aggressively corrected.
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19
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Abstract
Phosphorus (P) and calcium (Ca) serve vital roles in the human body and are essential components of nutrition support therapy. Regulation of P and regulation of Ca in the body are closely interrelated, and P and Ca homeostasis can be affected by several factors, including disease states, clinical condition, severity of illness, and medications. Nutrition support clinicians must understand these factors to prevent and treat P and Ca disorders in patients receiving nutrition support therapy. This review provides an overview of P and Ca for the adult nutrition support clinician, with some emphasis on the hospitalized inpatient.
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Affiliation(s)
- Michael D Kraft
- Department of Clinical, Social and Administrative Sciences, University of Michigan College of Pharmacy, Ann Arbor, Michigan Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Ann Arbor, Michigan
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20
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Bech A, Blans M, Raaijmakers M, Mulkens C, Telting D, de Boer H. Hypophosphatemia on the intensive care unit: Individualized phosphate replacement based on serum levels and distribution volume. J Crit Care 2013; 28:838-43. [DOI: 10.1016/j.jcrc.2013.03.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 02/27/2013] [Accepted: 03/03/2013] [Indexed: 11/30/2022]
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21
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Suzuki S, Egi M, Schneider AG, Bellomo R, Hart GK, Hegarty C. Hypophosphatemia in critically ill patients. J Crit Care 2013; 28:536.e9-19. [DOI: 10.1016/j.jcrc.2012.10.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 10/12/2012] [Accepted: 10/15/2012] [Indexed: 11/26/2022]
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22
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Felsenfeld AJ, Levine BS. Approach to Treatment of Hypophosphatemia. Am J Kidney Dis 2012; 60:655-61. [DOI: 10.1053/j.ajkd.2012.03.024] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 06/19/2012] [Indexed: 12/25/2022]
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23
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Mizumoto H, Mikami M, Oda H, Hata D. Refeeding syndrome in a small-for-dates micro-preemie receiving early parenteral nutrition. Pediatr Int 2012; 54:715-7. [PMID: 23005906 DOI: 10.1111/j.1442-200x.2012.03590.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This report describes a small-for-date extremely low birth weight infant who manifested bradycardic events, respiratory failure, and hemolytic jaundice during her first week of life. These complications were attributed to severe hypophosphatemia and hypokalemia. Inadequate supply and refeeding syndrome triggered by early aggressive parenteral nutrition were responsible for electrolyte abnormalities.
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Affiliation(s)
- Hiroshi Mizumoto
- Department of Pediatrics, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan.
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24
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25
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Rhoda KM, Porter MJ, Quintini C. Fluid and Electrolyte Management. JPEN J Parenter Enteral Nutr 2011; 35:675-85. [DOI: 10.1177/0148607111421913] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Kristen M. Rhoda
- Intestinal Rehabilitation and Transplant Program, Center for Human Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Mary Jo Porter
- Intestinal Rehabilitation and Transplant Program, Center for Human Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Cristiano Quintini
- Intestinal Rehabilitation and Transplant Program, Center for Human Nutrition, Cleveland Clinic, Cleveland, Ohio
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26
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Refeeding in anorexia nervosa: increased safety and efficiency through understanding the pathophysiology of protein calorie malnutrition. Curr Opin Pediatr 2011; 23:390-4. [PMID: 21670680 DOI: 10.1097/mop.0b013e3283487591] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This paper reviews recent publications about the physiology associated with adaptation to malnutrition and refeeding (including the refeeding syndrome) and clinical outcomes of refeeding paradigms. RECENT FINDINGS A number of recent reviews and original publications have highlighted important differences from the assumptions underpinning the current refeeding guidelines for patients with anorexia nervosa. The notion of 'starting low and going slow' with the prescription of daily calories seems unlikely to be important in preventing refeeding syndrome. Recent publications suggest this approach does not necessarily add to safety in the refeeding process but rather the contrary. It typically results in weight loss and protracts hospitalization and nutritional recovery. Rather, the composition of macronutrients, in particular avoiding a high proportion of calories from carbohydrates, appears to be more important than the absolute number of calories. The means of initial refeeding appears increasingly important in this process, particularly following descriptions of postprandial hypoglycemia. SUMMARY The study supports a review of the current guidelines. Evidence for the use of continuous feeding strategies with less than 40% of calories from carbohydrates is presented. This approach has important implications for the prevention of the refeeding syndrome as well as the safety and efficiency with which refeeding may occur for children and adolescents with anorexia nervosa in hospital.
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27
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Geerse DA, Bindels AJ, Kuiper MA, Roos AN, Spronk PE, Schultz MJ. Treatment of hypophosphatemia in the intensive care unit: a review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R147. [PMID: 20682049 PMCID: PMC2945130 DOI: 10.1186/cc9215] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Revised: 06/02/2010] [Accepted: 08/03/2010] [Indexed: 01/10/2023]
Abstract
Introduction Currently no evidence-based guideline exists for the approach to hypophosphatemia in critically ill patients. Methods We performed a narrative review of the medical literature to identify the incidence, symptoms, and treatment of hypophosphatemia in critically ill patients. Specifically, we searched for answers to the questions whether correction of hypophosphatemia is associated with improved outcome, and whether a certain treatment strategy is superior. Results Incidence: hypophosphatemia is frequently encountered in the intensive care unit; and critically ill patients are at increased risk for developing hypophosphatemia due to the presence of multiple causal factors. Symptoms: hypophosphatemia may lead to a multitude of symptoms, including cardiac and respiratory failure. Treatment: hypophosphatemia is generally corrected when it is symptomatic or severe. However, although multiple studies confirm the efficacy and safety of intravenous phosphate administration, it remains uncertain when and how to correct hypophosphatemia. Outcome: in some studies, hypophosphatemia was associated with higher mortality; a paucity of randomized controlled evidence exists for whether correction of hypophosphatemia improves the outcome in critically ill patients. Conclusions Additional studies addressing the current approach to hypophosphatemia in critically ill patients are required. Studies should focus on the association between hypophosphatemia and morbidity and/or mortality, as well as the effect of correction of this electrolyte disorder.
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Affiliation(s)
- Daniël A Geerse
- Department of Intensive Care Medicine, Catharina Hospital Eindhoven, Michelangelolaan 2, Eindhoven 5623 EJ, The Netherlands.
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Boateng AA, Sriram K, Meguid MM, Crook M. Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition 2010; 26:156-67. [PMID: 20122539 DOI: 10.1016/j.nut.2009.11.017] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 11/17/2009] [Accepted: 11/23/2009] [Indexed: 12/14/2022]
Abstract
Refeeding syndrome (RFS) represents a group of clinical findings that occur in severely malnourished individuals undergoing nutritional support. Cardiac arrhythmias, multisystem organ dysfunction, and death are the most severe symptoms observed. As the cachectic body attempts to reverse its adaptation to the starved state in response to the nutritional load, symptoms result from fluid and electrolyte imbalances, with hypophosphatemia playing a central role. Because guidelines for feeding the malnourished patient at risk for refeeding syndrome is scarce, we have provided management recommendations based on the knowledge derived from a collection of reported English literature cases of the RFS. A MEDLINE search using keywords including "refeeding syndrome," "RFS," and "refeeding hypophosphatemia" was performed. References from initial cases were utilized for more literature on the subject. We have emphasized the continued importance of managing patients at risk for RFS, compared how management of the severely malnourished patients have evolved over time, and provided comprehensive clinical guidelines based on the sum of experience documented in the case reports for the purpose of supplementing the guidelines available. Based on our review, the most effective means of preventing or treating RFS were the following: recognizing the patients at risk; providing adequate electrolyte, vitamin, and micronutrient supplementation; careful fluid resuscitation; cautious and gradual energy restoration; and monitoring of critical laboratory indices.
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Affiliation(s)
- Akwasi Afriyie Boateng
- Surgical Metabolism and Nutrition Laboratory, Department of Surgery, University Hospital, Upstate Medical University, State University of New York, Syracuse, NY 13210, USA
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Lindsey KA, Brown RO, Maish GO, Croce MA, Minard G, Dickerson RN. Influence of traumatic brain injury on potassium and phosphorus homeostasis in critically ill multiple trauma patients. Nutrition 2009; 26:784-90. [PMID: 20018481 DOI: 10.1016/j.nut.2009.08.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 07/23/2009] [Accepted: 08/06/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The intent of this study was to ascertain whether multiple trauma patients with traumatic brain injury (TBI) had lower serum concentrations of potassium and phosphorus and required more aggressive supplementation than multiple trauma patients without TBI. METHODS Ventilator-dependent adult patients without renal impairment who were admitted to the trauma intensive care unit or neurosurgical intensive care unit and who received enteral nutrition were evaluated for the first 14 d after hospital admission. Patients were grouped according to the presence or absence of TBI. Target serum concentrations for potassium and phosphorus were 4 mEq/L and 4 mg/dL, respectively. Electrolyte repletion therapy was given according to the nutritional support service guidelines. RESULTS Fifty trauma patients (25 with and without TBI) were studied. Daily serum potassium concentrations were consistently lower for those with TBI (P < or = 0.001), whereas the mean net potassium intake was greater (1.3 +/- 0.5 versus 0.7 +/- 0.3 mEq x kg(-1) x d(-1), respectively, P < or = 0.001). Serial serum phosphorus concentrations were similar between groups (P = NS) except for a significantly lower serum phosphorus concentration for trauma patients with TBI on day 3 after hospital admission (2.5 +/- 0.5 versus 2.9 +/- 0.7 mg/dL, respectively, P < or = 0.05). However, the mean net phosphorus intake was significantly greater for trauma patients with TBI (0.65 +/- 0.25 versus 0.45 +/- 0.17 mmol x kg(-1) x d(-1), P < or = 0.001). CONCLUSION Potassium and phosphorus requirements are greater for multiple trauma patients with TBI compared with those without TBI.
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Affiliation(s)
- Kimberly A Lindsey
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Patel U, Sriram K. Acute respiratory failure due to refeeding syndrome and hypophosphatemia induced by hypocaloric enteral nutrition. Nutrition 2009; 25:364-7. [DOI: 10.1016/j.nut.2008.09.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 07/12/2008] [Accepted: 09/18/2008] [Indexed: 01/30/2023]
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Crook MA. Management of severe hypophosphatemia. Nutrition 2009; 25:368-9. [DOI: 10.1016/j.nut.2008.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Accepted: 11/10/2008] [Indexed: 10/21/2022]
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Miller SJ. Death Resulting From Overzealous Total Parenteral Nutrition: The Refeeding Syndrome Revisited. Nutr Clin Pract 2008; 23:166-71. [DOI: 10.1177/0884533608314538] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sarah J. Miller
- From the Department of Pharmacy Practice, University of Montana, Missoula
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Owen P, Monahan MF, MacLaren R. Implementing and assessing an evidence-based electrolyte dosing order form in the medical ICU. Intensive Crit Care Nurs 2008; 24:8-19. [PMID: 17686630 DOI: 10.1016/j.iccn.2007.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Revised: 04/05/2007] [Accepted: 04/14/2007] [Indexed: 12/27/2022]
Abstract
UNLABELLED The purpose of this study was to evaluate the efficacy, safety, and nursing acceptability of a nursing initiated, evidence-based order form to replace potassium, magnesium, and phosphate in the MICU. METHODS This retrospective study compared patients receiving electrolyte replacement with the order form to matched historical control patients receiving traditional electrolyte replacement (no order form). The primary outcomes were absolute change in serum concentrations and the proportion of doses achieving normal serum concentrations. Other outcomes were adverse events as documented in the medical record and nursing acceptability as assessed by survey. RESULTS The 2 groups (12 in each group) were similar. The order form and control groups received 36 and 62 potassium doses, 14 and 48 magnesium doses, and 34 and 13 phosphorus doses, respectively. Doses of all three electrolytes were significantly larger with the order form. Absolute changes in potassium, magnesium, and phosphorus serum concentrations for the order form group and control group were 0.36+/-0.42 versus 0.11+/-0.43 mmol/l (p<0.01), 0.56+/-0.69 versus 0.13+/-0.40 mequiv./l (p=0.07), and 0.53+/-0.82 versus 0.66+/-0.83 mg/dl (p=0.63), respectively. Normal serum concentrations achieved for each electrolyte replacement dose in the order form group and control group were 72% versus 18% (p<0.001), 86% versus 21% (p<0.001), and 47% versus 62% (p=0.57), respectively. No adverse events occurred. The nursing survey showed satisfaction and comfort using the order form. CONCLUSIONS The use of the order form provided greater efficiency for replacing potassium and magnesium but not phosphorus without increasing the occurrence of adverse events. The order form was well received by nursing staff.
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Affiliation(s)
- Phillip Owen
- School of Pharmacy C238, Department of Clinical Pharmacy, University of Colorado at Denver and Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80262, USA
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Dickerson RN, Henry NY, Miller PL, Minard G, Brown RO. Low serum total calcium concentration as a marker of low serum ionized calcium concentration in critically ill patients receiving specialized nutrition support. Nutr Clin Pract 2007; 22:323-8. [PMID: 17507732 DOI: 10.1177/0115426507022003323] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The intent of this study was to ascertain to what extent serum total calcium concentration (tCa) <7 mg/dL reflects hypocalcemia (defined by ionized calcium concentration [iCa] of < or = 1.12 mmol/L) in critically ill patients receiving specialized nutrition support. METHODS Adult patients (> or = 18 years) admitted to the trauma, surgical, medical, burn, or neurosurgical intensive care units, trauma stepdown unit, or progressive care unit and referred to the nutrition support service were retrospectively identified for potential inclusion into the study. Serum chemistries, arterial blood gas measurements, nutrition markers, and serum iCa were simultaneously obtained from each patient approximately 1 day after initiation of specialized nutrition support. Patients with a serum creatinine > or = 2 mg/dL, hyperphosphatemia (> or = 6 mg/dL), severe hypomagnesemia (< or = 1.12 mg/dL), history of metabolic bone disease, or parathyroid disease were excluded from the analysis. RESULTS One hundred ninety-five patients (91% who had multiple trauma, with a mean Injury Severity Score 31 +/- 13) were enrolled into the study. Specialized nutrition support was initiated 2.8 +/- 1.8 days and calcium status was studied 4.2 +/- 3.1 days after hospital admission, respectively. The majority (28 of 33, or 85%) of patients with a tCa <7 mg/dL were hypocalcemic compared with 33% (22 out of 66) of patients with a tCa of 7-7.4 mg/dL, and 11% (11 of 96) of those with a tCa of 7.5-7.9 mg/dL (p < .001). CONCLUSIONS Critically ill patients with a serum total calcium concentration of <7 mg/dL have a high rate of hypocalcemia (iCa < or = 1.12 mmol/L). Hypocalcemia, defined as a serum iCa of < or = 1.12 mmol/L, occurs in 85% of acutely ill patients with a serum tCa <7 mg/dL.
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Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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Dickerson RN, Morgan LM, Croce MA, Minard G, Brown RO. Treatment of moderate to severe acute hypocalcemia in critically ill trauma patients. JPEN J Parenter Enteral Nutr 2007; 31:228-33. [PMID: 17463149 DOI: 10.1177/0148607107031003228] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Our recent data indicate that 21% of critically ill, adult, multiple-trauma patients receiving specialized nutrition support experience hypocalcemia. However, evidence-based methods for the treatment of moderate to severe acute hypocalcemia (ionized calcium concentration [iCa] <1 mmol/L) are lacking. METHODS The efficacy of an infusion of 4 g of calcium gluconate was evaluated in 20 critically ill, adult, multiple-trauma patients with moderate to severe hypocalcemia (iCa <1 mmol/L). The calcium gluconate was infused at a rate of 1 g/h in a small volume admixture. A serum iCa determination was obtained on the following day. RESULTS Calcium gluconate infusion significantly increased serum iCa from 0.90 +/- 0.08 mmol/L to 1.16 +/- 0.11 mmol/L (p < .001) on the following day. This dosage regimen was successful for achieving a serum iCa >1 mmol/L for 19 of 20 (95%) hypocalcemic patients and achieved a concentration >1.12 mmol/L in 14 (70%) of the patients. Two patients developed mild hypercalcemia (iCa of 1.34 mmol/L and 1.38 mmol/L) postinfusion. CONCLUSIONS A short-term infusion of 4 g of intravenous (IV) calcium gluconate for the treatment of moderate to severe hypocalcemia appears to be a promising regimen for critically ill, adult, multiple-trauma patients.
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Affiliation(s)
- Roland N Dickerson
- Department of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA.
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Dickerson RN, Morgan LM, Croce MA, Minard G, Brown RO. Dose-dependent characteristics of intravenous calcium therapy for hypocalcemic critically ill trauma patients receiving specialized nutritional support. Nutrition 2006; 23:9-15. [PMID: 17123782 DOI: 10.1016/j.nut.2006.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Revised: 09/27/2006] [Accepted: 10/01/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of this investigation was to evaluate the dose-dependent characteristics of intravenous calcium gluconate therapy for hypocalcemic critically ill patients. METHODS The dose-dependent characteristics of 2 g versus 4 g of intravenous calcium gluconate therapy were evaluated in 25 critically ill, adult multiple trauma patients with hypocalcemia. The calcium gluconate was infused at a rate of 1 g/h for both groups. Patients weighed within 90% to 120% of ideal body weight, had normal renal function, did not receive diuretic therapy, and did not have anasarca. RESULTS Fifteen patients with mild hypocalcemia (serum ionized calcium concentration [iCa] 1-1.12 mmol/L) were given 2 g of calcium gluconate. Ten patients with moderate to severe hypocalcemia (iCa <1 mmol/L) were given 4 g. Each dosage group had a significant (P < or = 0.001) increase in iCa (from 1.07 +/- 0.05 to 1.17 +/- 0.05 mmol/L and from 0.92 +/- 0.08 to 1.16 +/- 0.11 mmol/L, respectively). Each dosage group retained about half of the dose in the exchangeable calcium space (P = NS between groups), but the higher dosage group retained significantly more elemental calcium overall (81 +/- 38 versus 201 +/- 50 mg, respectively, P < or = 001). Serum ionized calcium concentrations achieved a plateau without a further decline in iCa by 10 h after completion of the infusion for each dosage. CONCLUSION About half of the administered elemental calcium dose was retained for each dosage group, with the higher dose (4 g) resulting in significantly more elemental calcium retention in the exchangeable calcium space. An iCa determination performed about > or =10 h after the completion of the calcium gluconate infusion should be sufficient time to ensure equilibration of iCa to assess the efficacy of the therapy. This mode of calcium therapy serves as an effective means for providing calcium to the acutely hypocalcemic, critically ill, multiple trauma patient.
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Affiliation(s)
- Roland N Dickerson
- Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
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