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Clinical controversies: Banana bags don’t really make a difference… : Emergency Medicine News

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fanny pack, intravenous hydration, alcohol use disorder, acute alcohol intoxication

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Intravenous hydration clinics are the latest thing, with real doctors touting the therapy as a way to relieve hangovers, build athletic endurance, lose weight and prevent burnout. Apparently, it’s such a booming business that even emergency care is getting into it.

We’re unlikely to start providing this in the emergency department, but one aspect of intravenous hydration needs our attention: fanny packs. These are given whenever a patient who has a history of alcohol use disorder or is acutely intoxicated presents to the emergency department. They seem harmless, but we should stop using them for many reasons. Banana bags may differ by facility, but most contain a host of parenteral multivitamins mixed in salt water or dextrose, including folate, B12, magnesium, and thiamin.

It is difficult to measure whether they help patients, but Li, et al., tried valiantly in 2008, finding in a prospective observational study that none of the 75 adult patients with acute alcohol intoxication who presented to a urban emergency department had no vitamin B12 or folate levels. below the normal range. (Am J Urgent Med. 2008;26[7]:792.) Only six patients had borderline low thiamine levels, none showing symptoms. No one had megaloblastic anemia either. This was a small, single-center study, but the results should still raise eyebrows.

Thiamine and Wernicke

Another study showed that folate deficiency rates in people with alcohol use disorders did not differ significantly from those in the general population. Only five of the 52 patients who had an alcohol use disorder had folate deficiency, compared to two of the 48 patients in the control group. No statistical difference was observed between the groups, so empirical folate administration was probably not necessary. (Am J Urgent Med. 1992;10[3]:203.)

Thiamine receives the most attention over other vitamins in people with alcohol use disorders due to the dreaded Wernicke’s encephalopathy. Many argue that it is necessary because Wernicke’s disease is difficult to diagnose and associated with a 20% mortality if left untreated. (J Neurol Neurosurg Psychiatry. 1986;49[4]:341; https://bityl.co/CmpA.)

Naturally, every doctor wants to avoid this pathology and empirically gives thiamine, and the fanny packs contain 100 mg of thiamine. This has traditionally been the recommended daily amount to treat Wernicke’s disease, but it was an arbitrary dose assigned in the 1950s, not based on scientific research.

Current research suggests that higher amounts of thiamine should be administered due to the short parenteral half-life. (Ann Emergency Med. 2007;50[6]:715.) Many experts now say that patients at risk should take 100 mg twice daily orally. But a fanny pack won’t solve the problem if you’re worried your patient has Wernicke’s disease.

Expensive and unnecessary

You’ll be shocked at how expensive fanny packs are, and the lack of evidence of their effectiveness seals the deal. A retrospective study of ERs found that educating ER doctors about unnecessary fanny pack orders for people with alcohol use disorders saved an average of $44,000 a year. (Ann Emergency Med. 2011;58[4 Suppl]:S257.)

The cost of a fanny pack depends on where you practice and your hospital costs, but many hydration clinics charge between $150 and $500 per infusion. (https://mobileivmedics.com. Accessed June 20, 2022.) Add overhead and emergency services personnel costs, and you could end up with a bill in the thousands.

Fanny packs aren’t just an expensive intravenous fluid, they’re also unnecessary. Several studies have shown that IV fluids alone do not increase ethanol metabolism or alter ED length of stay. (Emerg Med Australia. 2013;25[6]:527; https://bityl.co/CmpY.) Neither fanny packs nor IV fluids should be given to hasten the metabolism to sobriety in acutely intoxicated patients.

Oral “rally packs” are quite acceptable for patients who require vitamin supplementation. Most patients have no difficulty absorbing vitamins in their gastrointestinal tract. Oral multivitamins are naturally much cheaper than fanny packs, and they’re easier to give and take less time. (J Med Urgent. 1998;16[3]:419.)

We shouldn’t be surprised that fanny packs don’t have a significant impact on patient care. We tailor our approach to electrolyte and fluid replacement in each of our patients, and those with alcohol use disorders should be no different. A one-size-fits-all approach is inappropriate and we are not helping this vulnerable group of patients, even though hanging up a fanny pack makes us feel like we are.

Above all, take the time to sit down and talk with your patients who abuse alcohol. Discuss their eating habits and prescribe thiamin and other multivitamins. Talking to patients about prevention is always more effective than an expensive bag of liquids.

Thanks to Tom Benzoni, DO, for this topic suggestion.

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Dr. Briggsis an assistant professor of emergency medicine at the University of South Alabama in Mobile. He is the founder, podcast co-host and editor of EM Board Bombs (https://www.emboardbombs.com), a cross-platform educational tool designed to prepare for counseling and focus on what you need to know to practice emergency medicine. Follow him on Twitter@blakebriggsmd.