In this episode, I’ll:

1. Discuss an article about the use of banana bags in ICU patients.

2. Answer the drug information question “If a pharmacist programs an IV pump for infusion, does that count as administration?”

3. Share a resource that is a search engine containing a national compendium of package inserts.

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If you already have a copy of the book, it would be a tremendous help if you could write a brief review on Amazon. Reviews let others browsing the book know why you purchased it or how you use it in your practice to decide if it might help them. You can get to the book review page in Amazon by going here.

Article

Unpeeling the Evidence for the Banana Bag: Evidence-Based Recommendations for the Management of Alcohol-Associated Vitamin and Electrolyte Deficiencies in the ICU

Lead author: Alexander H. Flannery

Published in Critical Care Medicine August 2016

Background

ICU patients with alcohol withdrawal or chronic alcohol use disorder are often given a “banana bag” as standard therapy to replenish micronutrients and prevent Wernicke’s Encephalopathy.

Purpose

The authors assessed whether the contents and doses of micronutrients and electrolytes in standard banana bags met the needs of critically ill patients with an alcohol use disorder.

Methods

The authors searched pubmed.gov, the Cochrane Database of Systematic Reviews, and manually reviewed references of selected articles. Relevant articles were synthesized for the review. For reference, the authors considered a standard banana bag to be a liter of IV fluid plus a 10 mL vial of multivitamins, 100 mg of thiamine, 1 mg of folic acid, and 1-2 g of magnesium.

Results

Thiamine was noted to be the most important micronutrient to acutely correct in ICU patients with chronic alcohol use disorder. The amount of thiamine found in a standard banana bag is woefully inadequate to reliably treat or prevent Wernicke’s Encephalopathy. As discussed in episode 70, large doses of thiamine up to 500 mg IV q8 hrs should be considered.

Folic acid and magnesium were considered to have some benefit as supplements, although the data supporting this was not as strong as with thiamine.

No evidence was found to support the use of IV multivitamin for ICU patients with chronic alcohol use disorder.

Conclusion

The authors concluded:

Based on the published literature, for patients with a chronic alcohol use disorder admitted to the ICU with symptoms that may mimic or mask Wernicke’s encephalopathy, we suggest abandoning the banana bag and utilizing the following formula for routine supplementation during the first day of admission: 200-500 mg IV thiamine every 8 hours, 64 mg/kg magnesium sulfate (approximately 4-5 g for most adult patients), and 400-1,000 μg IV folate. If alcoholic ketoacidosis is suspected, dextrose-containing fluids are recommended over normal saline.

Discussion

I’ve always disliked banana bags. Especially when the order just says “banana bag” instead of listing the ingredients. In my “young and wild” pharmacist days I once sent a banana in a bag in response to one of these orders.

After reading this article, I will advocate to immediately stop using IV multivitamins in ICU patients with chronic alcohol use disorder.

The recommendations on thiamine from the authors of this study match those that I already follow.

I’m not as impressed with the need for folic acid replacement in these patients, and magnesium supplementation can be done per protocol.

I hope this article is the beginning of the end of the banana bag.

Drug information question

This question comes from the Pharmacy Nation Slack group (our free community for real-time discussion with other pharmacists). Frequent contributor “Pharmacy Z” asks:

Q: If a pharmacist programs an IV pump for infusion, does that count as administration?

A: I think they would need to connect it to the patient & hit start for it to count as administration.

In my own practice I will occasionally program the smart pump, but I prefer to let the nurse handle it whenever possible. I like to stick with spiking the IV bag, priming the tubing, and labeling the lines. “Pharmacy Chris” pointed out the value of having the nurse double check your work if you do set up the smart pump.

I’ve posed this question to pharmacists on Twitter. So far the results are:

Attention #pharmacists please comment – What do you do with smart pumps when at the bedside? — Pharmacy Joe (@PharmacyJoe) July 27, 2016

“Pharmacy Nadia” of EMPharmd.blogspot.com tweets:

@PharmacyJoe Spike IVPB, prime line, and program for appropriate drug, dosing weight, and rate of infusion for critical patients. 1/2 — Nadia I. Awad (@Nadia_EMPharmD) July 28, 2016

@PharmacyJoe This helps facilitate administration of meds; all that RNs need to do is connect line to patient and start the program. 2/2 — Nadia I. Awad (@Nadia_EMPharmD) July 28, 2016

I would love to know your thoughts on this question. You can let me know by joining the slack group and answering there, taking the poll on Twitter, or placing a comment below in the show notes.

Resource

The resource for this episode is DailyMed by the U.S. National Library of Medicine, and it was emailed in to me by “Pharmacy Mike.” He writes:

It’s a search engine containing the national compendium of package inserts. Has helped me with info that UpToDate or Micromedex can’t in both central pharmacy and clinical scenarios, such as storage/stability info, reconstitution info for nurses on the floor, and excipient information (for patients with red-dye allergies, on ketogenic diets, etc.). Also has vetrinary medications for the pet-owners out there. Nice tool to have at your fingertips, and also handy public-access resource in case one doesn’t have access to a tertiaryresource and needs med info like Grandma asking about random side-effects of lisinopril at Thanksgiving, haha!

Take care!

-Pharmacist Mike

Mike also pointed out to me that the link to DailyMed is a bit clunky to remember, so I have made a redirect that you can use – pharmacyjoe.com/DailyMed. Thanks Pharmacy Mike for the resource recommendation!

If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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