Incidence Of Hypophosphatemia Research Articles

Assessment of nephrotoxicity associated with combined cisplatin and mitomycin C usage in laparoscopic hyperthermic intraperitoneal chemotherapy

Background: Laparoscopic hyperthermic intraperitoneal chemotherapy (HIPEC) has been used to treat various peritoneal malignancies. Cisplatin and mitomycin C (MMC) are agents commonly used in these procedures and, individually, each has been associated with acute kidney injury (AKI). There is limited literature on the complications associated with the use of both agents in HIPEC. Therefore, we sought to determine the incidence of nephrotoxicity and electrolyte abnormalities in patients undergoing laparoscopic HIPEC using this chemotherapeutic combination.Methods: We retrospectively evaluated patients undergoing laparoscopic HIPEC for gastric or gastroesophageal adenocarcinoma using both cisplatin and MMC. Sodium thiosulfate was given for renal protection and kidney function was evaluated daily up to postoperative day #2. Details regarding patient characteristics, selection criteria, chemotherapeutic regimen, perioperative lab values and anesthetic management were collected.Results: Twenty-three patients underwent 31 laparoscopic HIPEC procedures. Fifteen (65%) were male and the median age was 57 (range 21–75). Thirteen procedures were associated with an elevation in creatinine (Cr) with the median difference between POD#2 and baseline being 0.09 mg/dL (range 0–0.43). The glomerular filtration rate median difference between POD#2 and baseline was −17 mL/min/1.37 sq. m (range −42 to 11). No cases demonstrated AKI, defined as a 50% increase in Cr levels above baseline. An 84% incidence of postoperative hypophosphatemia (26/31) and 94% incidence of postoperative hypocalcemia (29/31) was observed.Conclusion: The laparoscopic approach to HIPEC using both cisplatin and MMC in our cohort was not associated with an increased incidence of AKI. The incidence of hypophosphatemia and hypocalcemia needs further evaluation to determine the exact etiology.Precis’ statement: We retrospectively studied the association of AKI with the combined use of cisplatin and MMC in laparoscopic HIPEC.

Hypophosphatemia after High Dosage Iron Substitution with Ferric Carboxymaltose (FCM) and Iron Isomaltoside (IM) — the Randomised Controlled Home Afers 1 Trial

In iron deficiency anaemia patients, intravenous administration of either ferric carboxymaltose (FCM) or iron isomaltoside (IM) both allow high dosage iron substitution within a single outpatient visit. In contrast, other iron compounds require repetitive, low dosage infusions. Recently, FCM was reported to frequently induce acute, reversible hypophosphatemia. It remains enigmatic whether these hypophosphataemic effects of FCM are substance-specific, or whether they generally occur after high dosage iron substitution. A direct comparison of phosphorus regulation after high dosage iron substitution with either FCM or IM is clinically important, as hypophosphatemia after FCM has anecdotally been associated with osteomalacia and bone fractures.In the HOMe AFers 1 (HOMburg evaluations on application of Ferrum study 1) trial, we recruited normophosphatemic women with gynaecological bleeding and subsequent iron deficiency anaemia, in whom we assessed the longitudinal biochemical response over 28 days to a single intravenous injection of equivalent doses of randomly-assigned FCM and IM (1000 mg). The primary study hypothesis was that the incidence of hypophosphatemia - defined as plasma phosphorus < 2.0 mg/dl at least out of three post-infusion study time points (day 1, day 8, and week 5) - differs between FCM and IM. HOMe AFers 1 initially planned to recruit 60 women. An interim analysis was pre-specified and scheduled in July 2018, with the option to stop further patient recruitment if the incidence of hypophosphatemia differs significantly at this interim analysis.At the time point of the interim analysis, 26 patients have been recruited. One patient withdrew her acceptance to participate after day 1, leaving 25 patients for our per protocol interim analysis. Baseline plasma phosphorus did not differ significantly between FMC (3.3 ± 0.4 mg/dl) and IM (3.6 ± 0.6 mg/dl; p = 0.135). Analysis on the primary endpoint demonstrated that significantly more women developed hypophosphatemia < 2.0 mg/dl after FMC infusion (9 out of 12 patients) than after IM infusion (1 out of 13 patient) (p=0.001). Further, the minimum plasma phosphorus during any of the three post-infusion study time points was lower after FMC (1.8 ± 0.3 mg/dl) than after IM (2.7 ± 0.6 mg/dl; p < 0.001). As expected, ferritin and haemoglobin increased in both study groups after iron infusion. No severe adverse events occurred in either group.In conclusion, while both FCM and IM provide efficient iron substitution in iron deficiency anaemia, FCM induced a substantially higher incidence of hypophosphatemia. DisclosuresEmrich:Pharmacosmos: Consultancy, Honoraria, Research Funding. Stilgenbauer:Mundipharma: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pharmcyclics: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Sanofi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Genentech: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Genzyme: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Boehringer-Ingelheim: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Hoffmann La-Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; GSK: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Brandenburg:Pharmacosmos: Consultancy, Honoraria, Research Funding; Vifor: Consultancy, Honoraria. Heine:Pharmacosmos: Consultancy, Honoraria, Research Funding.

OP01-4 - Hypophosphatemia after cardiopulmonary bypass - Incidence and clinical significance

Hypophosphatemia, after cardiopulmonary bypass, has been described in the postoperative period.(1) Clinical implications include: increases in length of intensive care unit (ICU) stay, length of ventilation and need in cardioactive drug requirements.(2) Incidence of hypophosphatemia and the impact on the above mentioned postoperative care variables were evaluated in a South African population (Bloemfontein).

Phosphate disturbance in critically ill children: Incidence, associated risk factors and clinical outcomes.

BackgroundHypophosphatemia is one of the common disorders that develop in critically ill patients. It has potential complications and is often unrecognized in those patients.ObjectiveDetermining the incidence of hypophosphatemia in critically ill children, its association with clinical outcomes and the possible risk factors.Methods50 patients were enrolled in the study. Levels of serum phosphate were measured on day 1 and day 7 of PICU (Pediatric intensive care unit) stay. The following variables were analyzed: age, gender, diagnosis on admission, malnutrition, phosphorus intake, clinical severity score on admission OFI (Organ Failure Index) and daily scores PELOD (Pediatric Logistic Organ Dysfunction), sepsis, use of dopamine, furosemide and steroids and assessment of nutrition by z scores.ResultsThe incidence of hypophosphatemia on admission was 42%. On seventh day of admission incidence of hypophosphatemia was 62%. Malnutrition was present in 24% of patients, serum phosphorus level was significantly lower in malnourished than in well-nourished children (p value = 0.018). Hypophosphatemia was associated with prolonged PICU length of stay (p < 0.001) but was not associated with increased mortality (p = 0.13). Cases on parenteral nutrition and insufficient oral intake while on mechanical ventilator significantly showed hypophosphatemia (p = 0.017). Hypophosphatemia was associated with the use of furosemide, dopamine, steroids and β2 agonist.ConclusionHypophosphatemia was common in the first 7 days of PICU hospitalization and was associated with prolonged PICU stay, Significant association between hypophosphatemia and duration of use of mechanical ventilation, use of furosemide, dopamine, steroids and β2 agonist.

Incidence of hypophosphatemia in not critically ill patients with enteral feeding

Up to 30-40% of the patients starting artificial nutritional support develop hypophosphatemia. In general, patients with mild and moderate hypophosphatemia do not have symptoms, but severe hypophosphatemia is the hallmark of refeeding syndrome. To determine the incidence of hypophosphatemia in not critically ill patients receiving enteral feeding. Prospective study. We assessed during seven days 181 not critically ill patients started on enteral artificial nutrition support during seven days. 51.9% of the patients were considered to be at risk of developing refeeding syndrome (United Kingdom National Institute for Health and Clinical Excellence criteria). The incidence of hypophosphatemia was 31.5%, but only 1.1% of the patients developed severe hypophosphatemia. Older age and lower plasma proteins were significantly associated with hypophosphatemia. The incidence of severe hypophosphatemia in our study is low, so we can't offer robust conclusions about the risk of hypophosphatemia in the type of patients receiving enteral nutrition.

Preventing Continuous Renal Replacement Therapy-Induced Hypophosphatemia: An Extended Clinical Experience with a Phosphate-Containing Solution in the Setting of Regional Citrate Anticoagulation

Aims: To evaluate the efficacy and safety of a commercially available phosphate-containing solution for continuous renal replacement therapy (CRRT) in preventing CRRT-related hypophosphatemia. Methods: In heart surgery patients undergoing continuous veno-venous haemodiafiltration (CVVHDF) with regional citrate anticoagulation (RCA), we combined an 18 mmol/l citrate solution with a phosphate-containing (1.2 mmol/l) dialysate/replacement fluid evaluating the incidence of hypophosphatemia and the need for parenteral phosphorus supplementation. Results: In 75 patients on RCA-CVVHDF, the mean filter life was 53.9 ± 33.6 h. Regardless of baseline levels, phosphoremia was progressively corrected and maintained in a narrow normality range throughout RCA-CRRT days (after 72 h: 1.14 ± 0.25 mmol/l). Considering the whole CRRT period, 45 out of 975 (4.6%) serum phosphorus determinations met the criteria for mild (<0.81 mmol/l) or moderate (<0.61 mmol/l) hypophosphatemia; severe hypophosphatemia (<0.32 mmol/l) never occurred. After 72 h 88% of the patients were normophosphatemic, 9% hyperphosphatemic and 3% hypophosphatemic. Conclusions: RCA-CVVHDF with a phosphate-containing solution enabled the maintenance of phosphorus levels within normophosphatemic range in most of the patients, minimizing the occurrence of CRRT-related hypophosphatemia.

Incidence of hypophosphatemia in advanced cancer patients: a recent report from a single institution

Recent approval of molecular-targeted agents has contributed to improving the therapeutic outcomes of advanced cancer patients. However, they result in unusual adverse events that rarely occur with cytotoxic agents, such as hypertension, hypomagnesemia, and an acne-like rash. Although hypophosphatemia can be induced by various agents, some kinds of molecular-targeted agents are known to induce it. In addition, cancer survivors may be at a risk of hypophosphatemia. One hundred and seventy patients, who visited the Department of Clinical Oncology at Akita University from 1 April 2014 to 31 August 2016 were enrolled in this study after providing informed consent. Serum inorganic phosphorus levels were examined along with other routine clinical examinations. Correlation between the serum inorganic phosphorus level and other clinical data were also analyzed. Grade ≥2 severe hypophosphatemia (<2.5mg/dL of phosphorus) was detected in 49.4% of patients, and grade ≥3 (<2.0mg/dL of phosphorus) was observed in 22.9% patients. These results indicated that the presence of bone metastasis (p<0.001), history of bone-modifying agents (p<0.001) and molecular-targeted drugs (p=0.001), and time from the date of the first visit to the date of minimum serum phosphorus level (p<0.001) might correlate with hypophosphatemia. Multivariate logistic regression analysis showed that disease duration might be a risk factor (p=0.0466). As hypophosphatemia can be induced by various factors in advanced cancer patients, the serum phosphorus level of cancer patients at risk should be cautiously examined.

An Institutional Change in Continuous Renal Replacement Therapy: Nutrition Support Team Resolves Resultant Severe Hypophosphatemia.

Critically ill patients with acute kidney injury may require parenteral nutrition (PN) and continuous renal replacement therapy (CRRT). Introduction of a phosphate-free premixed renal replacement fluid without system-wide education in May 2011 resulted in increased incidence of hypophosphatemia, necessitating change in practice. Changes included (1) maximizing phosphate in PN, (2) modifying the CRRT order set, and (3) developing a CRRT competency evaluation for nutrition support team members. This study evaluates the effect of these changes on the incidence of hypophosphatemia. Phosphate levels and predicated probability of hypophosphatemia were evaluated for patients receiving PN and CRRT over 3 time periods: prior to implementing the changes (preimplementation), during change implementation (intermediate), and following implementation (postimplementation). Hypophosphatemia was defined as a serum phosphate level <2.5 mg/dL. Generalized linear mixed models were applied for statistical analysis. The retrospective study includes 336 measures from 49 patients. Patients in the intermediate and postimplementation periods were not significantly different from each other and had significantly higher mean phosphate levels than patients in the preimplementation period (P < .0001). They were also less likely to develop hypophosphatemia compared with preimplementation patients (intermediate: odds ratio [OR], 0.07; 95% confidence interval [CI], 0.03-0.18, P < .0001; postimplementation: OR, 0.09; 95% CI, 0.03-0.27, P < .0001). Modifications in phosphate dosing together with CRRT education reduced the incidence of hypophosphatemia in PN patients receiving CRRT. Communication of significant changes in clinical care should be shared with all services prior to implementation. Communication and planning between services caring for complex patients are necessary to prevent systems-based problems.

Hypophosphatemia in Enterally Fed Patients in the Surgical Intensive Care Unit: Common but Unrelated to Timing of Initiation or Aggressiveness of Nutrition Delivery.

Hypophosphatemia has been associated with refeeding malnourished patients, but its clinical significance is unclear. We investigated the incidence of refeeding hypophosphatemia (RH) in the surgical intensive care unit (SICU) and its association with early enteral nutrition (EN) administration and clinical outcomes. We performed a retrospective review of a 2-year database of patients receiving EN in the SICU. RH was defined as a post-EN phosphorus (PHOS) level decrement of >0.5 mg/dL to a nadir <2.0 mg/dL within 8 days from EN initiation. We investigated the risk factors for RH and examined its association with clinical outcomes using multivariable regression analyses. In total, 213 patients comprised our analytic cohort. Eighty-three of 213 (39%) individuals experienced RH and 43 of 130 (33%) of the remaining patients experienced non-RH hypophosphatemia (nadir PHOS level <2.0 mg/dL). Overall, there was a total 59% incidence of hypophosphatemia of any cause (N = 126). Nutrition parameters did not differ between groups; most patients were initiated on EN within 48 hours of SICU admission, and timing of EN initiation was not a significant predictor for the development of RH. The median hospital length of stay (LOS) was 21 and 24 days for those with and without RH, respectively (P = .79); RH remained a nonsignificant predictor for hospital LOS in the multivariable analysis. RH is common in the SICU but is not related to timing or amount of EN. Hypophosphatemia is also common in the critically ill, but regardless of etiology, it was not found to be a predictor of worse clinical outcomes.

EARLY AGGRESSIVE TOTAL PARENTERAL NUTRITION TO PREMATURE INFANTS IN NEONATAL INTENSIVE CARE UNIT

Introduction: Iatrogenic intrauterine growth restriction in NICU has been a prevailing problem in these days when smaller babies are being salvaged. Early aggressive TPN is defined when total of 4g/kg/day of amino acid is administrated via standardized TPN to neonates over first week of life. Our main objective of the study is to evaluate the efficacy, safety and tolerability of early aggressive standardized TPN to infants. We also explore the impact of early and high dose of amino acid with hypophosphatemia in extreme low birth weight (ELBW) infants, growth velocity in infants with TPN therapy and TPN cost when the hang time is extended from 24 hours to 48 hours. Methods: This is a prospective study on premature infants in NICU, Sarawak General Hospital for 6 months. Demographics and anthropometric data of eligible infants were collected. Biochemical test, growth velocity and cost of TPN therapy were analysed. Results: There are 69 eligible infants recruited. Serum electrolytes of all infants were found to be within normal range throughout TPN therapy except serum phosphate concentration. We found that incidence of hypophosphatemia is high with high amino acid supply in ELBW infants. There is a negative correlation (-0.26) between serum urea concentration and birth weight. Targeted growth velocity is achieved with standardized TPN and ELBW premature infants were found to have highest weight growth velocity. By extending TPN hang time to 48 hours, TPN related cost is associated with minimizing and resulted in yearly savings of RM 62556.60, exclusive of labour cost and nursing cost. Conclusion: Early aggressive PN therapy is safe and it achieved goal of postnatal growth velocity and body composition in premature infants. This study also demonstrated that the current practice of extending hang time is financially beneficial to hospital.

ABSTRACT 251

Background and aims: Hypophosphatemia is common in critically ill adults and may be responsible for serious consequences. Aims: In view of scant data, we determined the incidence of hypophosphatemia in critically ill children. Methods: A cohort study of children aged 1 month to 15 years admitted in PICU was conducted over 18 months period. Serum phosphate was measured by colorimetric method within 24 hours of admission (Day 1), Day 3, Day 7 and Day 10. Serum albumin, calcium, alkaline phosphatase (ALP) were also measured. Patients were monitored for 10 days of PICU stay. Hypophosphatemia was defined as serum phosphate <3.8 mg/dL for children younger than 2 years and <3.5 mg/dL for children 2 years or older. Associations with mortality, length of stay and mechanical ventilation were determined. The study was approved by Ethics Committee. Results: Three hundred and forty nine children were screened and 162 children were enrolled. One hundred and sixteen (71.6%) children had hypophosphatemia. Of the 90 children who did not have hypophosphatemia on day 1, 44 (48.9%) developed hypophosphatemia subsequently. The mortality in the hypophosphatemic group was 43.9% as compared to 39.1% in the non-hypophosphatemic group; p=0.57. Median length of PICU stay was 7 days in hypophosphatemic group compared to that of 4 days in non-hypophosphatemic group (p=0.001). Serum phosphate <2.5 mg/dL was associated with mortality with an adjusted OR of 4.2 [95%CI: 1.4–12.5]. Conclusions: Hypophosphatemia was common in critically ill children and was associated with prolonged length of stay and increased duration of mechanical ventilation. Serum phosphate <2.5 mg/dL was associated with increased mortality.

Preventing continuous renal replacement therapies (CRRT)-induced hypophosphatemia using a phosphate-containing CRRT solution in the setting of regional citrate anticoagulation

Phosphate depletion is a known issue during continuous renal replacement therapies (CRRT) with an incidence of hypophosphatemia up to 80% when standard CRRT solutions are used. The aim was to evaluate the effects on serum phosphate and phosphorus supplementation needs of a regional citrate anticoagulation (RCA) protocol for CRRT combining the use of citrate with a phosphate-containing CRRT solution.

Higher Caloric Intake in Hospitalized Adolescents With Anorexia Nervosa Is Associated With Reduced Length of Stay and No Increased Rate of Refeeding Syndrome

To determine the effect of higher caloric intake on weight gain, length of stay (LOS), and incidence of hypophosphatemia, hypomagnesemia, and hypokalemia in adolescents hospitalized with anorexia nervosa. Electronic medical records of all subjects 10-21 years of age with anorexia nervosa, first admitted to a tertiary children's hospital from Jan 2007 to Dec 2011, were retrospectively reviewed. Demographic factors, anthropometric measures, incidence of hypophosphatemia (≤3.0 mg/dL), hypomagnesemia (≤1.7 mg/dL), and hypokalemia (≤3.5 mEq/L), and daily change in percent median body mass index (BMI) (%mBMI) from baseline were recorded. Subjects started on higher-calorie diets (≥1,400 kcal/d) were compared with those started on lower-calorie diets (<1,400 kcal/d). A total of 310 subjects met eligibility criteria (age, 16.1 ± 2.3 years; 88.4% female, 78.5 ± 8.3 %mBMI), including 88 in the lower-calorie group (1,163 ± 107 kcal/d; range, 720-1,320 kcal/d) and 222 in the higher-calorie group (1,557 ± 265 kcal/d; range, 1,400-2,800 kcal/d). Neither group had initial weight loss. The %mBMI increased significantly (p < .001) from baseline by day 1 in the higher-calorie group and day 2 in the lower-calorie group. Compared with the lower-calorie group, the higher-calorie group had reduced LOS (13.0 ± 7.3 days versus 16.6 ± 9.0 days; p < .0001), but the groups did not differ in rate of change in %mBMI (p = .50) or rates of hypophosphatemia (p = .49), hypomagnesemia (p = 1.0), or hypokalemia (p = .35). Hypophosphatemia was associated with %mBMI on admission (p = .004) but not caloric intake (p = .14). A higher caloric diet on admission is associated with reduced LOS, but not increased rate of weight gain or rates of hypophosphatemia, hypomagnesemia, or hypokalemia. Refeeding hypophosphatemia depends on the degree of malnutrition but not prescribed caloric intake, within the range studied.

Refeeding syndrome in very-low-birth-weight intrauterine growth-restricted neonates

Determine the incidence of refeeding syndrome, defined by the presence of hypophosphatemia in very-low-birth-weight (VLBW) infants with intrauterine growth restriction (IUGR) compared with those without IUGR. In this retrospective cohort study, VLBW infants admitted over a 10-year period (271 IUGR and 1982 non-IUGR) were evaluated for specific electrolyte abnormalities in the first postnatal week. IUGR infants were significantly more likely to have hypophosphatemia (41% vs 8.9%, relative risk (95% confidence interval: 7.25 (5.45, 9.65)) and severe hypophosphatemia (11.4% vs 1%, 12.06 (6.82, 21.33)) in the first postnatal week. The incidence of hypophosphatemia was significantly associated with the presence of maternal preeclampsia in all VLBW infants (odds ratio (OR): 2.58 (1.96, 3.40)) when controlling for birth weight and gestational age. Refeeding syndrome occurs in VLBW infants with IUGR and born to mothers with preeclampsia. Close monitoring of electrolytes, especially phosphorus, is warranted in this population.

Hypophosphatemia during continuous veno-venous hemofiltration is associated with mortality in critically ill patients with acute kidney injury

IntroductionThe primary aim of this study was to determine whether hypophosphatemia during continuous veno-venous hemofiltration (CVVH) is associated with the global outcome of critically ill patients with acute kidney injury (AKI).Methods760 patients diagnosed with AKI and had received CVVH therapy were retrospectively recruited. Death during the 28-day period and survival at 28 days after initiation of CVVH were used as endpoints. Demographic and clinical data including serum phosphorus levels were recorded along with clinical outcome. Hypophosphatemia was defined according to the colorimetric method as serum phosphorus levels < 0.81 mmol/L (2.5 mg/dL), and severe hypophosphatemia was defined as serum phosphorus levels < 0.32 mmol/L (1 mg/dL). The ratio of CVVH therapy days with hypophosphatemia over total CVVH therapy days was calculated to reflect the persistence of hypophosphatemia.ResultsThe Cox proportional hazard survival model analysis indicated that the incidence of hypophosphatemia or even severe hypophosphatemia was not associated with 28-day mortality independently (p = 0.700). Further analysis with the sub-cohort of patients who had developed hypophosphatemia during the CVVH therapy period indicated that the mean ratio of CVVH therapy days with hypophosphatemia over total CVVH therapy days was 0.58, and the ratio independently associated with the global outcome. Compared with the patients with low ratio (< 0.58), those with high ratio (≥ 0.58) conferred a 1.451-fold increase in 28-day mortality rate (95% CI 1.103–1.910, p = 0.008).ConclusionsHypophosphatemia during CVVH associated with the global clinical outcome of critically ill patients with AKI. The ratio of CVVH therapy days with hypophosphatemia over total CVVH therapy days was independently associated with the 28-day mortality, and high ratio conferred higher mortality rate.

Change of serum phosphate level and clinical outcome of hypophosphatemia in massive burn patient

Hypophosphatemia is relatively common phenomenon in patients with massive burn injury. Therefore, we check serum phosphate level routinely and try to supply phosphate in a timely manner. The purpose of this study was to investigate the change of the serum phosphate level of early postburn period and the impact of hypophosphatemia on the prognosis of patients. A total of 227 patients with burn injury were reviewed retrospectively. We performed analysis of serum phosphate level within 20 days from burn injury. Patients' mean (SD) age was 47.0 (14.1) years, and mean (SD) percentage of total body surface area burned were 47.7 (21.9). Severe hypophosphatemia (phosphate < 1.0 mg/dL) was observed in 35 patients (15.8%), and moderate hypophosphatemia (1.0 ≤ phosphate < 2.0 mg/dL) was found in 115 patients (50.6%). Therefore, overall incidence of hypophosphatemia was 66.4%. There was no significant difference in serum phosphate level with survival, total body surface area burned, and mechanical ventilation. Age (odds ratio [OR], 3.180; 95% confidence interval [CI], 1.025-9.871; p = 0.045), total body surface area burned (OR, 20.934; 95% CI, 6.845-64.024; p = 0.000), and mechanical ventilation (OR, 5.581; 95% CI, 2.380-13.085; p = 0.002) were independently associated with mortality. However, serum phosphate level (OR, 0.828; 95% CI, 0.275-2.495; p = 0.737) does not have a statistical significance. Although multiple studies have evaluated the efficacy and safety of phosphate repletion regimens, the effect on mortality and morbidity is not well reported. However, our results show that patients with massive burn injury have high incidence of hypophosphatemia, and hypophosphatemia can result in many complications. Therefore, routine check and supply of phosphate can be suggested in patients with massive burn injury. Prognostic study, level II.

1355 Incidence of Serum Hypophosphatemia in Growth Restricted and Appropriately Grown Preterm Infants

BackgroundInfants with intrauterine growth restriction (IUGR) often have metabolic and electrolyte abnormalities. Our aim was to determine the incidence of hypophosphatemia in IUGR versus appropriate for gestational age (AGA) premature...

Nutritional status and complications in children with diabetic ketoacidosis

Diabetic ketoacidosis in children continues to be an important cause of morbidity and mortality, especially in developing economies as a result of malnutrition, a high rate of infections, and delay in seeking timely medical care. Malnutrition also increases the risk of diabetic ketoacidosis-related complications. The objective of this study was to assess the nutritional status of patients presenting with diabetic ketoacidosis and correlate it with the incidence of complications at presentation and those encountered during the course of illness. Prospective study. Pediatric emergency and intensive care units, Advanced Pediatrics Centre, PGIMER, Chandigarh, India. Thirty-three children between 1 month and 12 yrs of age presenting with diabetic ketoacidosis between July 2008 and June 2009 were enrolled consecutively and assessed for nutritional status by anthropometric parameters (body weight, crown-heel length/height, mid-upper arm circumference, triceps and subscapular skin fold thicknesses), biochemical parameters (serum albumin, zinc, magnesium, vitamin A levels), and preillness dietary history (by pretested Food Frequency Questionnaire). Patients were classified as malnourished or normally nourished based on the weight for age criteria matched for Indian standards. The incidence of complications (electrolyte imbalances, hypoglycemia, sepsis, cerebral edema, etc.) and outcome in terms of survival or death in both the groups were compared with Student's t-test for parametric data, Mann-Whitney U test for nonparametric data, and chi-square test for categorical variables. None. Anthropometric assessment showed that 11 of 33 (33.3%) were malnourished. Preillness dietary history revealed that 16 (48.5%) were calorie- and protein-deficient (known diabetic n = 7; new onset n = 9), whereas 11 (33.3%) were only calorie-deficient (known diabetic n = 2). Hypoalbuminemia was seen in 21 (63.6%), hypovitaminosis A in eight (24.2%), and low zinc levels in three (9%). The malnourished and normally nourished groups were similar with respect to demographics, precipitating factors, severity of diabetic ketoacidosis, treatment received, and outcome. However, the incidence and severity of therapy-related hypokalemia (100% vs. 72.7%; p = .05) and hypoglycemia (63.6 vs. 13.6%; p = .004) were significantly higher in the former as compared with the latter. The mean ± SD admission serum potassium levels were similar in both the groups (3.4 ± 0.8 mEq/L in the malnourished vs. 3.5 ± 0.7 mEq/L in the normally nourished) with the malnourished group showing a significant fall at 6 hrs after start the of diabetic ketoacidosis protocol (2.8 ± 0.8 mEq/L vs. 3.6 ± 0.7 mEq/L; p = .033), although the mean rate and dose of insulin infusion were similar. The fall in blood glucose (mean ± SD mg/dL) at 12, 24, and 36 hrs after onset of the diabetic ketoacidosis protocol was also significantly greater in the malnourished group as compared with the normally nourished diabetic ketoacidosis (195 ± 69.1 and 272.61 ± 96.3, p = .02; 171 ± 58.5 and 257 ± 96.3, p = .05; and 153.75 ± 49.6 and 241.71 ± 76.3, p = .04, respectively). The incidence of hypophosphatemia, hypomagnesemia, cerebral edema, renal failure, sepsis, and septic shock was similar in both the groups. There were two deaths, both resulting from complicating cerebral edema and renal failure and unrelated to the nutritional status of the patients. The incidence and severity of therapy-related hypokalemia and hypoglycemia were significantly higher in the malnourished as compared to the normally nourished diabetic ketoacidosis. Other diabetic ketoacidosis-related complications and outcome were similar in both the groups.

Hypophosphatemia in the Intensive Care Unit: Incidence, Predictors and Management

Introduction: Our objectives are to identify the incidence of hypophosphatemia and the associated risk factors. We also want to establish intravenous replacement therapy that is effective for ICU patients. Methods: A prospective observational study assessing adults admitted to ICU in between March and May 2009. All patients without baseline phosphate level and renal failure were excluded. They were evaluated for the occurrence of common risk factors. Association with independent variables that includes age, gender and BMI were verified. Evaluation of IV replacement therapy was done in the treated patients. Results: From 50 patients that were reviewed, nine were excluded. There were 66% male and 34% female with mean age 46.88±17.89. The mean ICU stay was 8.00±6.41 days. The incidence of hypophosphatemia was 29% (n=12/41). Gender and creatinine clearance was found to be significantly different between normophosphatemia and hypophosphatemia patients. There was no significant association for each potential risk factor and the number of risk factors (≥3) with the incidence of hypophosphatemia. Multi-linear regression analysis showed that lactate, creatinine clearance and pH were significant predictors to the serum levels. A significant difference of mean serum phosphate was seen after repletion by total dose of 10, 20 and 40 mmols in the treatment subgroups. Conclusions: The incidence of hypophosphatemia in our ICU was high and comparable to previous studies. None of the commonly reported risk factors is associated with hypophosphatemia in this studied population. Among all significant correlated variables, only pH was found to be a significant predictor for serum phosphate. Baseline phosphate level may guide the initial replacement dose to prevent delay in normalization of serum levels.

The occurrence of hypophosphatemia and its prognostic value in intensive care unit patients

To investigate the occurrence of hypophosphatemia in intensive care unit (ICU) patients, and to study the influence of different levels of phosphorus on the prognosis of patients. One hundred and forty-seven patients admitted to Shengjing Hospital during April to November in 2010 were enrolled. The serum phosphorous level was measured consecutively, and the incidence of hypophosphatemia was observed. Acute physiology and chronic health evaluation II (APACHE II ) score, length of ICU-stay, the main laboratory findings and mortality were compared among patients with different serum phosphate levels. Receiver operating characteristic curve (ROC curve) was plotted according to the serum phosphate level and the survivability of patients to study the prognostic value of serum phosphate level in the ICU patients. A large number of ICU patients (77.6%) had developed hypophosphatemia, mild in 21, midrange in 70, and marked in 23, amounting to 63.3% of patients suffering from medium and marked hypophosphatemia. The APACHE II score, duration of artificial ventilation (days), length of ICU-stay (days) as well as mortality rate were higher in hypophosphatemia patients compared with those of the normal group (APACHE II score: mild 18.2 ± 6.0, midrange 21.4 ± 7.6, marked 25.6 ± 8.8, normal 18.9 ± 8.8; length of artificial ventilation: mild 6.6 ± 5.1, midrange 11.3 ± 9.5, marked 15.7 ± 10.4, normal 6.7 ± 5.9; length of ICU-stay: mild 9.7 ± 6.4, medium 10.6 ± 8.2, marked 18.9 ± 13.1, normal 9.9 ± 7.1; mortality rate: mild 14.3%, medium 25.7%, marked 39.1%, normal 9.1%). The mortality of ICU patients (22.4%) was negatively correlated with the degree of hypophosphatemia (r = -0.225, P = 0.01). The serum phosphate level had a prognostic value when it was less than 0.40 mmol/L, with sensitivity of 78.6%, specificity of 51.5%. For most of ICU patients, the serum phosphorus is at a relatively low level. ICU patients have multiple risk factors to develop hypophosphatemia and severe hypophosphatemia is a predictor of a poor prognosis.