Preferences for the measurement and supplementation of magnesium, phosphate and zinc in ICUs: The international WhyTrace survey

Vesterlund, Gitte Kingo; Ostermann, Marlies; Myatra, Sheila Nainan; Arabi, Yaseen M.; Sadat, Musharaf; Zampieri, Fernando G.; Cronhjort, Maria; Schefold, Joerg C.; Stöhr, Frederik; Buanes, Eirik Alnes; Bäcklund, Minna; Þormar, Katrín; Perner, Anders

doi:10.1111/aas.13738

Cited by 7 publications

(12 citation statements)

References 18 publications

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“…Among the 334 survey respondents (mainly physicians), only 24.3% reported monitoring iron, folate, B12 and a few others: 51.4% reported early administration of combined multivitamin and trace element preparations in selected patients. Another international survey with a high 84% response rate [4] showed that 62% of the ICUs reported standard procedures for magnesium, 58% for phosphate and 9% for zinc, with administration protocols available in similar numbers, again with a wide variation between ICUs.…”

Section: Who Measures and Administers Micronutrients?mentioning

confidence: 99%

An update on essential micronutrients in critical illness

Berger

2023

Current Opinion in Critical Care

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Purpose of review Numerous micronutrients are involved in antioxidant and immune defence, while their blood concentrations are frequently low in critically ill patients: this has fuelled many supplementation trials. Numerous observational, randomized studies have been published, which are presented herein. Recent findings Micronutrient concentrations must be analysed considering the context of the inflammatory response in critical illness. Low levels do not always indicate a deficiency without objective micronutrients losses with biological fluids. Nevertheless, higher needs and deficiencies are frequent for some micronutrients, such as thiamine, vitamins C and D, selenium, zinc and iron, and have been acknowledged with identifying patients at risk, such as those requiring continuous renal replacement therapy (CRRT). The most important trials and progress in understanding have occurred with vitamin D (25(OH)D), iron and carnitine. Vitamin D blood levels less than 12 ng/ml are associated with poor clinical outcomes: supplementation in deficient ICU patients generates favourable metabolic changes and decreases mortality. Single high-dose 25(OH)D should not be delivered anymore, as boluses induce a negative feedback mechanism causing inhibition of this vitamin. Iron-deficient anaemia is frequent and can be treated safely with high-dose intravenous iron under the guidance of hepcidin to confirm deficiency diagnosis. Summary The needs in critical illness are higher than those of healthy individuals and must be covered to support immunity. Monitoring selected micronutrients is justified in patients requiring more prolonged ICU therapy. Actual results point towards combinations of essential micronutrients at doses below upper tolerable levels. Finally, the time of high-dose micronutrient monotherapy is probably over.

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Section: Who Measures and Administers Micronutrients?mentioning

confidence: 99%

An update on essential micronutrients in critical illness

Berger

2023

Current Opinion in Critical Care

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“…1,5 Many adult ICU patients receive supplementation, but clinical equipoise exists as indicated by data from a survey among 283 ICUs across 10 countries. 6 Of the surveyed ICUs approximately 35% did not have a procedure for supplementation of magnesium and phosphate in general ICU patients, and 85% did not have a procedure for zinc supplementation. 6 The serum levels of magnesium and phosphate, were most often measured daily or twice per week, and Zinc most often once or twice per week in the ICUs with a procedure zinc measurements.…”

Section: Introductionmentioning

confidence: 99%

“…6 Of the surveyed ICUs approximately 35% did not have a procedure for supplementation of magnesium and phosphate in general ICU patients, and 85% did not have a procedure for zinc supplementation. 6 The serum levels of magnesium and phosphate, were most often measured daily or twice per week, and Zinc most often once or twice per week in the ICUs with a procedure zinc measurements. A Danish guideline on nutrition in critically ill patients recommends two weekly measurements of magnesium, phosphate and zinc after the first three ICU days.…”

Section: Introductionmentioning

confidence: 99%

“…Many adult ICU patients receive supplementation, but clinical equipoise exists as indicated by data from a survey among 283 ICUs across 10 countries 6 . Of the surveyed ICUs approximately 35% did not have a procedure for supplementation of magnesium and phosphate in general ICU patients, and 85% did not have a procedure for zinc supplementation 6 .…”

Section: Introductionmentioning

confidence: 99%

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Effects of magnesium, phosphate, or zinc supplementation in intensive care unit patients—A systematic review and meta‐analysis

Vesterlund

Jensen

Ellekjær

et al. 2023

Acta Anaesthesiol Scand

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Background Low‐serum levels of magnesium, phosphate, and zinc are observed in many intensive care unit (ICU) patients, but clinical equipoise exists regarding supplementation strategies. We aimed to assess the desirable and undesirable effects of supplementation with magnesium, phosphate, or zinc in adult ICU patients. Methods We conducted a systematic review with meta‐analysis of randomised clinical trials assessing the effects of supplementation with magnesium, phosphate, or zinc in adult ICU patients. Primary outcomes were mortality and duration of mechanical ventilation. We registered the protocol, followed the Preferred Reporting Items for Systematic Review and Meta‐Analysis statement, used the Cochrane risk of bias 2 tool, and the grading of recommendations, assessment, development and evaluation (GRADE) approach for assessing the certainty of the evidence. Results We identified no low risk of bias trials. For magnesium supplementation, we included three trials (n = 235); the relative risk (RR) for mortality was 0.54, 95% confidence interval (CI) 0.30–0.96 compared to no supplementation (very low certainty of evidence). For zinc supplementation, two trials were included (n = 168); the RR for mortality was 0.73, 95% CI 0.41–1.28 compared to control. No trials assessed the effects of phosphate supplementation on mortality. For outcomes other than mortality, only zero or one trial was available. Conclusions In adult ICU patients, the certainty of evidence for the effects of supplementation with magnesium, phosphate, or zinc was very low. High‐quality trials are needed to assess the value of supplementation strategies in these patients.

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“…2,4,6 We have previously found a marked variation in the reported assessment and administration of magnesium, phosphate and zinc among ICUs. 7 As an important next step, we aim to describe the clinical landscape including the prevalence, management of supplementation, characteristics and outcomes of patients with low levels of these minerals in a large cohort of Danish ICU patients.…”

Section: Introduction 11 Backgroundmentioning

confidence: 99%

Low serum levels of magnesium, phosphate, and zinc in ICU patients – prevalence, management, characteristics, and outcomes Protocol and statistical analysis plan for The WhyTrace cohort study

Vesterlund

Thorsen-Meyer

Kaas‐Hansen

et al. 2022

Preprint

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BackgroundPatients admitted to the intensive care unit often have low serum levels of magnesium, phosphate, and zinc. We aim to describe the prevalence, management, characteristics, and outcomes of patients with low levels of these minerals in a large cohort of Danish ICU patients.MethodsIn this multicenter cohort, we will include all adult ICU patients admitted to one of 10 ICUs during a six years period. Patients will be excluded if the ICU admission is post-operative after planned surgery, length of stay is <24 hours, they are transferred from ICUs not participating in the study, or are without measurements of neither magnesium, phosphate nor zinc. First, we will do a descriptive assessment of the prevalence of low serum levels and management of supplementation according to different patient characteristics. Second, we will conduct a cohort study using prospectively registered outcome data, to assess associations between serum levels of magnesium, phosphate, and zinc respectively, and each of two principal outcomes: time to successful extubation and incident tachyarrhythmia. We will use a joint modelling approach for estimating the strengths of associations, combining time to event data and longitudinal data from repeated measurements of serum levels.DiscussionThis study will provide information from a very large cohort of Danish ICU patients. Strengths of the study will be the large number of patients, the interconnection of data from several registers, and for the association analysis the use of a statistical approach making the optimal use of the repeated measures of serum levels. Limitations will be the risk of bias from unmeasured or unregistered confounding factors, and the lack of randomization in the observational design, which will prevent us from interpreting possible associations between serum levels and outcomes as definite effects on the outcome.

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Preferences for the measurement and supplementation of magnesium, phosphate and zinc in ICUs: The international WhyTrace survey

Cited by 7 publications

References 18 publications

An update on essential micronutrients in critical illness

An update on essential micronutrients in critical illness

Effects of magnesium, phosphate, or zinc supplementation in intensive care unit patients—A systematic review and meta‐analysis

Low serum levels of magnesium, phosphate, and zinc in ICU patients – prevalence, management, characteristics, and outcomes Protocol and statistical analysis plan for The WhyTrace cohort study

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