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Negaard BJ, Vakkalanka JP, Nugent AS, Faine BA. Long-Term Impacts of a Targeted Intervention in the Emergency Department on Inpatient Prescribing Practices. J Pharm Pract 2024; 37:60-65. [PMID: 36052770 DOI: 10.1177/08971900221125077] [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] [Indexed: 11/16/2022]
Abstract
Background: In 2009, researchers successfully implemented an intervention to decrease the inappropriate prescribing of multivitamin infusions (MVIs) in the emergency department (ED) for patients presenting with alcohol-related illnesses. Objective: The purposes of our study were to determine the impact of the 2009 intervention on hospital-wide prescribing practices of vitamin therapies for alcohol-related illnesses, and to evaluate its long-term sustainability. Methods: A retrospective observational cohort study was conducted at a 60,000-visit ED, 811-bed academically-affiliated tertiary referral hospital with an average census of 515 and 714 patients in 2009 and 2019, respectively. Patients were included if they presented to the ED from 2009 to 2019 with an alcohol-related illness as defined by ICD-9 and ICD-10 codes. The primary outcome was the change in the monthly average of MVIs ordered inpatient within the first four months compared to the last four months of the study period. Secondary outcomes included changes in the mean distribution (MD) per month of thiamine administrations in the ED and inpatient setting, and MVIs ordered in the ED. Results: The MD of MVIs ordered per month decreased by 3.5% (95% CI -5.3, -1.7) in the inpatient setting and decreased by 1.4% (95% CI -2.5, -.3) in the ED from the beginning to the end of our study period. Conclusions: This study suggests the effects of an intervention made in the ED sustained impact over a 10-year timeframe, and decreased the use of MVIs in both the ED and hospital-wide.
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Affiliation(s)
- Briana J Negaard
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - J Priyanka Vakkalanka
- Department of Emergency Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA; Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Andrew S Nugent
- Department of Emergency Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Brett A Faine
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Department of Emergency Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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Urticaria by thiamine (vitamin B1). Allergol Int 2018; 67:276-277. [PMID: 28843441 DOI: 10.1016/j.alit.2017.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/03/2017] [Accepted: 07/04/2017] [Indexed: 11/21/2022] Open
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Juel J, Pareek M, Langfrits CS, Jensen SE. Anaphylactic shock and cardiac arrest caused by thiamine infusion. BMJ Case Rep 2013; 2013:bcr-2013-009648. [PMID: 23853017 DOI: 10.1136/bcr-2013-009648] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Parenteral thiamine has a very high safety profile. The most common adverse effect is local irritation; however, anaphylactic or anaphylactoid reactions may occur, mostly related to intravenous administration. We describe a 44-year-old man, a chronic alcoholic, who was admitted with alcohol intoxication and developed cardiac arrest due to anaphylactic shock following intravenous thiamine infusion. The patient was successfully resuscitated after 15 min and repeated epinephrine administrations. He was discharged in good health after 14 days. This case report emphasises both the importance of recognising the symptoms of anaphylaxis and the fact that facilities for treating anaphylaxis and cardiopulmonary resuscitation should be available when thiamine or for that matter, any drug is given in-hospital.
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Affiliation(s)
- Jacob Juel
- Department of Cardiology, Aarhus University Hospital, Aalborg Hospital, Aalborg, Denmark.
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4
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Multivitamin "banana bags" provide little value in emergency department patients. Ann Emerg Med 2012; 59:414-5. [PMID: 22525531 DOI: 10.1016/j.annemergmed.2011.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 10/05/2011] [Accepted: 11/01/2011] [Indexed: 11/20/2022]
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5
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Wernicke’s encephalopathy during parenteral nutrition in a Crohn’s disease patient. Nutrition 2011; 27:503-4. [DOI: 10.1016/j.nut.2010.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 11/11/2010] [Accepted: 12/03/2010] [Indexed: 11/22/2022]
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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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Kuwata Y, Tsuruoka S, Ohkuchi A, Matsubara S, Izumi A, Suzuki M. Serious adverse drug reaction in a woman with hyperemesis gravidarum after first exposure to vitamin B complex containing vitamins B1, B6 and B12. J Obstet Gynaecol Res 2009; 35:790-3. [DOI: 10.1111/j.1447-0756.2009.01021.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Donnino MW, Vega J, Miller J, Walsh M. Myths and misconceptions of Wernicke's encephalopathy: what every emergency physician should know. Ann Emerg Med 2007; 50:715-21. [PMID: 17681641 DOI: 10.1016/j.annemergmed.2007.02.007] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2006] [Revised: 01/20/2007] [Accepted: 02/06/2007] [Indexed: 12/25/2022]
Abstract
First described in 1881, Wernicke's encephalopathy continues to be an unrecognized and often misunderstood disease. The cause of Wernicke's encephalopathy is thiamine deficiency as a result of any nutritionally deficient state, though many physicians erroneously consider this disease to be confined only to alcoholics. Unfortunately, the syndrome is most often recognized only on autopsy, especially among nonalcoholics. Despite advances in magnetic resonance imaging, Wernicke's encephalopathy remains primarily a clinical diagnosis. The common clinical findings include mental status changes, ocular dysfunction, and gait ataxia. Additional signs may be present, or 1 or more of the common findings may be absent. Treatment mandates timely intravenous thiamine therapy, for which the optimum dosage remains controversial. This review traces the history of Wernicke's encephalopathy from the first description to our current understanding of the disease and includes many of the misconceptions, myths, and controversies that surround this disease. Emergency physicians need to be well versed in the varied presentation of Wernicke's encephalopathy because most of these patients will present to the emergency department and are oftentimes unrecognized. Further, physician knowledge of this disease is vital because the failure to diagnose results in severe neurologic morbidity and possible mortality, but the treatment is safe and effective.
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Affiliation(s)
- Michael W Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Erickson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose. Emerg Med Clin North Am 2007; 25:249-81; abstract vii. [PMID: 17482020 DOI: 10.1016/j.emc.2007.02.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Toxic overdose can present with various clinical signs and symptoms. These may be the only clues to diagnosis when the cause of toxicity is unknown at the time of initial assessment. The prognosis and clinical course of recovery of a patient poisoned by a specific agent depends largely on the quality of care delivered within the first few hours in the emergency setting. Usually the drug or toxin can be quickly identified by a careful history, a directed physical examination, and commonly available laboratory tests. Once the patient has been stabilized, the physician must consider how to minimize the bioavailability of toxin not yet absorbed, which antidotes (if any) to administer, and if other measures to enhance elimination are necessary.
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Affiliation(s)
- Timothy B Erickson
- Department of Emergency Medicine, Division of Clinical Toxicology, University of Illinois at Chicago, Toxikon Consortium, Chicago, IL 60612, USA.
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A case report of Wernicke's encephalopathy in a pediatric patient with anorexia nervosa--restricting type. J Adolesc Health 2007; 40:376-83. [PMID: 17367738 DOI: 10.1016/j.jadohealth.2006.11.140] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2006] [Revised: 11/03/2006] [Accepted: 11/14/2006] [Indexed: 11/22/2022]
Abstract
PURPOSE To describe a case of Wernicke's encephalopathy in a 15-year-old female patient with anorexia nervosa--restricting type. METHOD The patient and family were interviewed. Literature relevant to the case was reviewed prior to diagnosis. RESULTS The patient reported a 30-kg weight loss over a 6-month period, following a strict diet deplete in thiamine without vitamin supplementation. The patient reported a carbohydrate binge for 5 days prior to admission. Her clinical presentation, confusion, ataxia, nystagmus, and magnetic resonance imaging demonstrating bilateral subthalamic hyperdensities were consistent with Wernicke's encephalopathy. Nutritional stabilization and parenteral thiamine replacement resulted in rapid improvement of her ataxia and nystagmus and contributed to her recovery. CONCLUSIONS Wernicke's encephalopathy should be considered in patients with anorexia nervosa. Thiamine therapy could be considered in cases of anorexia nervosa with significant confusion.
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Compher C. Vitamins. Clin Nutr 2005. [DOI: 10.1016/b978-0-7216-0379-7.50016-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Klein M, Weksler N, Gurman GM. Fatal metabolic acidosis caused by thiamine deficiency. J Emerg Med 2004; 26:301-3. [PMID: 15028327 DOI: 10.1016/j.jemermed.2003.11.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2003] [Revised: 09/19/2003] [Accepted: 11/05/2003] [Indexed: 10/26/2022]
Abstract
Acute thiamine deficiency, an uncommon cause of hemodynamic instability in Western countries, may be manifested by acute heart failure and neurological deficits. Severe metabolic acidosis is one of its least recognized features. We present a report of foreign workers who complained of weakness and lower limb edema and were found to have acute thiamine deficiency. One died of refractory metabolic acidosis and shock, and the diagnosis was reached post mortem. Thiamine deficiency should be considered in every case of severe lactic acidosis without an obvious cause, especially in high-risk populations (malnourished, alcoholics, Far-East workers, etc). Whenever it is suspected, empiric treatment with thiamine should be initiated immediately. Physicians who care for populations at risk should be familiar with the clinical spectrum of nutritional deficits, and monitor the nutritional habits of these patients carefully. The treatment is inexpensive and devoid of adverse effects. Moreover, delaying thiamine administration in patients with deficiency may cause severe life-threatening metabolic acidosis and affect recovery. The prophylactic use of thiamine in a high-risk population, even before blood levels are received, may be cost effective.
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Affiliation(s)
- Moti Klein
- General Intensive Care Department, Division of Anesthesiology and Intensive Care, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Gabrielli A, Caruso L, Stacpoole PW. Early recognition of acute cardiovascular beriberi by interpretation of hemodynamics. J Clin Anesth 2001; 13:230-8. [PMID: 11377164 DOI: 10.1016/s0952-8180(01)00246-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Acute fulminant cardiovascular beriberi is an acute thiamine deficiency, which, if not recognized and treated, can lead to high cardiac output failure and death. The symptoms of acute thiamine deficiency include severe lactacidemia, and the presence of a high cardiac output and extremely low oxygen consumption in a patient who is hemodynamically stable. In this case conference, we describe a patient who was diagnosed with acute cardiovascular beriberi.
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Affiliation(s)
- A Gabrielli
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610-0254, USA
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