Intoxicated ED patients: banana bag or just a banana (hold the bag)?

May 1, 2012, 12:05 am

★★★☆☆

Providing Intravenous Multivitamins (Banana Bags) to Emergency Department Patients With Suspected Malnutritional Deficits. Ann Emerg Med 2012 May;59:413-415.

No abstract available

This is a part of the Annals’ “Clinical Controversies” series of debates on topics in emergency medicine. The question: should emergency physicians administer empiric intravenous multivitamins (the “banana bag”) to patients with suspected malnutrition or vitamin deficiencies? (Patients suspected of having these conditions are often alcoholics.)
Arguing the “pro” position is Kenneth Darren Katz, from the Division of Medical Toxicology at the University of Pittsburgh. He notes that alcoholic patients can have multiple causes of vitamin deficiencies, including poor diet, malabsorption, renal wasting, and metabolic derangements. Although Dr. Katz admits that data showing that banana bags provide clinical benefit are “extraordinarily limited” (that is, lacking), it still is advisable to give empiric parenteral vitamins and magnesium. He argues that the cost of this intervention is comparable to the cost of, say, giving parenteral antibiotics for pneumonia. He sums up: ” . . .administration of a parenteral banana bag is reasonable, potentially helpful, inexpensive, and safe therapy for the malnourished alcoholic patient and should remain an integral part of the emergency physician’s treatment armamentarium.”

Writing against the routine administration of “banana bags” is Frank LoVecchio of the Drug information Center at Maricopa Medical Center in Phoenix. He maintains that giving IV vitamins empirically is not in fact safe, but carries rare but real risks including anaphylaxis and transmission of blood-borne diseases. He cites a paper by Li et al (Am J Emerg Med 2008;26:792) that studied 77 emergency department patients presenting with acute alcohol intoxication. B12 and folate levels were within normal limits in the 75 patient in whom they were measured. Only 6 of test patients had low thiamine levels, and none had clinical evidence of thiamine deficiency. (It’s interesting that on the “pro” side Dr. Katz did not address this paper.) Dr. LoVecchio concludes that: ” . . . clinicians should reserve the use of vitamin and mineral supplementation to the alcoholic patient with a confirmed deficiency or presumed disease state . . .”

I give the bout to the “con” side (Dr. LoVecchio) on points.

 

4 Comments:

  1. Matthieu G. Says:

    “6 out of 75 patients had low thiamine level”

    What is the financial and societal cost of a 50-60yo patient ending up in a nursing home with Korsakoff dementia?

    I’ve seen too many of them. Until this question has been properly addressed, I will still give parenteral thiamine (no “banana bag” and no magnesium) to all chronic alcoholic patient going through my ED. How many drug given routinely are more expensive with a much higher NNT for dubious clinical endpoints?

  2. Leon Says:

    Matthieu:

    Thank you for your comment, which also gives me the opportunity to expand on the arguments put forth in the “Annals” debate. The question on the floor was really not about the indications for thiamine supplementation, but about the routine administration of intravenous multivitamins. Certainly if an alcoholic patient or any other with a condition that raised the consideration of malnutrition — such as cancer, AIDS, anorexia, hyperemesis gravidarum, etc — was given IV carbohydrate (e.g., D50W) one would want to administer parenteral thiamine within a reasonable interval but not necessarily before. If no IV carbohydrate was given and the patient discharged, it seems to me the important factor would be long-term improved nutrition and vitamin supplementation — I know of no evidence that a one-time dose of thiamine would offer benefit. I agree with the conclusions of the paper by Li et al mentioned in the post:

    “Pateitns presenting to our ED with acute ethanol intoxication do not have B-12 and folate deficiencies. A significant minority (15%) of patients have thiamine deficiency; its clinical significance is unclear. Widespread administration of multivitamins is unwarranted by these findings, but thiamine may be considered.”

  3. Michael Says:

    Leon,
    I happen to be quite familiar with the patient population that Li et al, sampled. The bias in this paper which was not disclosed was that many of the patients that he chose to sample are frequent users of Jacobi. In addition, those very same patients are often transported by the EMS system to other nearby hospitals where they very likely had been given the bannana bag. Just because he did not administer the cocktail himself does not mean that they were not given it a short time before they had their levels checked.

  4. Leon Says:

    Michael:

    Thank you. That’s a great point, and does seem a significant limitation to their study that should have been discussed. I’m still not sure there’s much evidence that a one-time (or intermittent) dose of B-12 or folate gives benefit, but agree that parenteral thiamine (IM or IV) should be administered liberally to patients who appear to be malnourished.