Turn Your Back on the Rally Pack?!

The Gist:  Multivitamin infusions (MVIs), fondly referred to as "banana bags" or "rally packs," are routinely administered in many emergency departments to individuals presenting with acute alcohol intoxication or other signs of alcoholism.  The standard practice of administering banana bags to individuals suspected of alcoholism or those with acute alcohol intoxication may not be necessary or beneficial.  Targeting these interventions to the population most at risk is likely to be more in line with current evidence.

The study:

• Faine et al,  address the utilization of MVIs in the Emergency Department (ED).  The study, evaluating the administration of vitamin supplements to patients presenting with alcohol related illnesses, demonstrates that educational interventions can effectively decrease unnecessary MVI without sacrificing patient health.  ED physicians reduced vitamin therapy by half after initiation of the intervention.  Additionally, many of the patients who received vitamin supplementation during the intervention phase of the study received more targeted vitamin repletion with tablets and/or IV/IM thiamine.

What's typically in a MVI?

• Vit A, D, E, K, Folic Acid, cyanocobalamin, biotin, pyridoxine, riboflavin, niacinamide, pantothenic acid, thiamine, ascorbic acid (1).

Why do we give MVIs to alcoholic patients?

• Malnourished 
• Apparently, beverages such as Wild Irish Rose and Coors Light aren't full of vitamins and nutrients.  Additionally, these patients may place alcohol above food in their hierarchy of needs.
• Vitamin deficiencies due to
• Poor oral intake
• Poor intestinal absorption 
• Decreased hepatic storage
• Notoriously deficient in: 
• Thiamine
• Note:  testing a patient's thiamine levels is inefficient and typically takes days, thus there is a case for treating suspected thiamine deficiency empirically
• Magnesium
• Folate
• B12
• More common in those with chronic alcoholism than those with an acute intoxication
• Potential to precipitate Wernicke's Encephalopathy in thiamine deficient patients if glucose load precedes thiamine repletion 
• Wernicke's encephalopathy is characterized by pathologic changes in the brain (vascular congestion, demyelination, petechial hemorrhages, etc) classically affecting the mamillary bodies and structures surrounding the third and fourth ventricles, leading to bad neurological sequelae (3)
• Treatment = thiamine repletion and confusion and neurological symptoms may resolve within hours to weeks
• Clinical diagnosis with a classic triad of:  opthalmoplegia, ataxia, and altered mental status
• Nystagmus is the most common ocular feature (3)
• An acute administration of glucose prior to thiamine supplementation apparently does not necessarily precipitate Wernicke's Encephalopathy (4).
• Very few side effects
• Thiamine can cause anaphylaxis, rarely (3)
• Tradition 

What's the downside to MVI empirically in patients in the ED with alcohol related illnesses?

• Cost ($20-40 per bag compared with a much less expensive parenteral thiamine injection or a multivitamin tab <$1.00)
• Sloppy shotgun medicine
• Targets everyone to prevent complications in a minority of patients
• Provides only transient benefit
• Paucity of evidence regarding dosing of short-term MVI in preventing adverse outcomes/sequelae (4)
• Anaphylaxis from parenteral vitamins 

"But, it's just a banana bag"... The Annals issue had opposing viewpoints on the issue, and Dr. Leon Gussow moderates the two in this post on The Poison Review.

• Katz, in a viewpoint piece in the same edition of annals attempts to justify the empiric use of MVIs by touting the benign nature of the MVI and the ranking of the cost of a banana bag compared with other ED interventions (5).  
• Does not address the actual efficacy of the MVI in preventing complications within this population nor any notion of a number needed to treat or risk reduction.  

In my opinion (as a lowly medical student), not doing harm to a patient is not equivalent to intervening effectively, efficiently, and beneficially for a patient.  I believe that the argument to move away from empiric MVI therapy in ED is based in using one's sense to determine an individual's patient need for vitamin repletion, as well as the means mechanism to achieve repletion.  The very sick patients who have a story consistent with chronic alcoholism, or those undergoing alcohol detoxification, could probably still benefit from a banana bag or, more importantly, a routine mechanism of vitamin supplementation (or alcohol abstinence).

References:

1.  Fain B, Nunge M, Denning G, Nugent A. Implementing Evidence-Based Changes in Emergency Department Treatment: Alternative Vitamin Therapy for Alcohol-Related Illnesses. Annals of Emergency Medicine Volume 59, Issue 5, May 2012, Pages 408–412

2.  S.F. Li, J. Jacob, J. Feng et al. Vitamin deficiencies in acutely intoxicated patients in the ED Am J Emerg Med, 26 (2008), pp. 792–795

3.  Charness M, So Y.  Wernicke's encephalopathy.  http://www.uptodate.com.ezproxylocal.library.nova.edu/contents/wernickes-encephalopathy?source=search_result&search=wernicke%27s+encephalopathy&selectedTitle=1~44#H2
4.  Donnino M, Vega J, Miller J, Walsh M.  Myths and Misconceptions of Wernicke’s Encephalopathy: What Every Emergency Physician Should Know.  Annals of Emergency Medicine Volume 50, Issue 6, December 2007, Pages 715-721
5  Katz, K.  Patients Who May Have Nutritional Deficits Annals of Emergency Medicine Volume 59, Issue 5, May 2012, Pages 413–414