We evaluated the effect of hypophosphatemia on mortality and length of stay in intensive care unit (ICU) patients. Ann Intern Med 1971, 74: 562-568. Serum phosphate levels do not accurately reflect total body phosphorus stores; hence the degree of hypophosphatemia does not always correlate to the presence of symptoms. Treatment: hypophosphatemia is generally corrected when it is symptomatic or severe. Taking this into account, the indication for -- and recommended frequency of -- laboratory monitoring and treatment remains debatable. Currently, no widely agreed-on guidelines exist concerning the approach to hypophosphatemia in critically ill patients, because evidence is lacking on when and how to treat hypophosphatemia. 10.1097/00007611-198707000-00008. https://doi.org/10.1186/s12871-019-0746-2, DOI: https://doi.org/10.1186/s12871-019-0746-2. Padelli M, Leven C, Sakka M, Plée-Gautier E, Carré JL. 2018;30(1):34–40. In a review of clinical studies done on hypophosphatemia in pediatric intensive care unit (PICU) patients, its prevalence exceeded 50% [2]. Nutr Hosp 2006, 21: 657-660. Schwartz A, Gurman G, Cohen G, Gilutz H, Brill S, Schily M, Gurevitch B, Shoenfeld Y: Association between hypophosphatemia and cardiac arrhythmias in the early stages of sepsis. Perreault MM, Ostrop NJ, Tierney MG: Efficacy and safety of intravenous phosphate replacement in critically ill patients. Renal phosphate handling is altered in trauma patients, resulting in inadequately increased urinary phosphate excretion. observed an association between hypophosphatemia that developed in 28.8% of heterogenous cohort of patients and mortality. Introduction: 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. Causes, consequences and treatment of hypophosphatemia: A systematic review. Hypophosphatemia can be asymptomatic but may as well be accompanied by fatal clinical complications, leading to poor outcomes in critically ill patients. Whether maintenance of normal plasma phosphate level and correction of the hypophosphatemia in critically -ill-patients can improve outcome is currently unknown. The Impact of Persistent Hypophosphatemia During CRRT on ICU Outcomes 50-80% of patients develop hypophosphatemia during RRT 5-7, and even patients with initial hyperphosphatemia may become hypophosphatemic when phosphate-free solutions are used 8. As can be seen in Table 1, the levels of serum albumin and serum potassium in the hypophosphatemia group were lower than those in the control group, but no difference was detected in the serum calcium, creatinine levels and GFR. Gaasbeek A, Meinders AE: Hypophosphatemia: an update on its etiology and treatment. Eur J Cardiothorac Surg 2004, 26: 306-310. A waiver for informed consent was obtained for this retrospective cohort study as data were analyzed anonymously. The hypophosphatemia was 15% in critically ill patients admitted in Medical and ICU Units. The patients were 62.41 ± 17.06 years old; 65.3% were male. Below are the links to the authors’ original submitted files for images. Hypophosphatemia is a serum phosphate concentration < 2.5 mg/dL (0.81 mmol/L). Miller CJ, Doepker BA, Springer AN, Exline MC, Phillips G, Murphy CV. 2013;7(4):407–15. Hyperphosphatemia (inorganic phosphate [iP] concentration > 1.4 mmol/L) occurred in 45% and hypophosphatemia (iP ≤ 0.6 mmol/L) in 20%. Intensive Care Med 2004, 30: 1662-1665. Privacy The data can be accessed with permission from Institutional Ethics Committee of the Six Affiliated Hospital, Sun Yat-sen University by contacting the corresponding author. Hypophosphatemia is even more frequent in burn-wound victims, where phosphate is lost through the skin [19, 20]. Chest 1983, 83: 504-508. 81% California Privacy Statement, Clin Sci (Lond) 2000, 98: 619-625. Anaesthesia 1999, 54: 198. The medical record of each patient who met the inclusion/exclusion criteria were reviewed to collect the following data: (1) age, (2) sex, (3) reason for ICU admission,(4) underlying disease,(5) medications, (6) nutrition, (7) Acute Physiology and Chronic Health Evaluation (APACHE II), levels of (8) phosphate, (9) potassium, (10) creatinine, (11) serum calcium, (12) serum albumin, and (13) glomerular filtration rate (GFR) patient admission to the ICU; the medical treatment included (14) mechanical ventilator time and (15) renal replacement therapy time. The cohort included 946 patients with a median phosphate concentration of 0.77 mmol/L (interquartile range 0.55–1.03 mmol/L). The aim of this study was to investigate whether hypophosphatemia can be a … Therefore, further studies in larger populations are required to confirm our findings. In patients with head trauma, induction of polyuresis may be an aggravating factor [21]. Ann Clin Lab Sci. Redistribution across the cell membrane is the most common cause of hypophosphatemia in ICU patients and can be caused by multiple clinical conditions [1, 3]: respiratory alkalosis-induced increase of intracellular pH causes phosphate to enter the cell by stimulating glycolysis [4]; administration of glucose and insulin also stimulates carbohydrate metabolism, during which phosphate is transported into the cells along with glucose; high serum levels of catecholamines such as epinephrine and norepinephrine, whether endogenous or exogenous, cause a decrease in serum phosphate [5]; cellular uptake of phosphate is increased under certain specific conditions such as the hungry-bone syndrome, and diseases with rapid cell proliferation such as acute leukemia; renal excretion of phosphate is increased by metabolic acidosis, and by many drugs, including diuretics, glucocorticoids [6], aminoglycosides, antiretroviral drugs, and anticancer drugs. Fiaccadori E, Coffrini E, Fracchia C, Rampulla C, Montagna T, Borghetti A. Hypophosphatemia and phosphorus depletion in respiratory and peripheral muscles of patients with respiratory failure due to COPD. To confirm this assumption, a single-center retrospective cohort study was conducted to determine whether patients with hypophosphatemia had higher mortality than patients with normal serum phosphate levels. Table 2 summarizes the reported incidence and prevalence of hypophosphatemia in surgical and medical ICU patients. Results: Incidence: hypophosphatemia is frequently encountered in the intensive care unit; and critically ill patients are at increased risk for developing hypophosphatemia due to the presence of multiple causal factors. Listing a study does not mean it has been evaluated by the U.S. Federal Government. It is generally recommended to correct hypophosphatemia in hypophosphatemic patients with associated symptoms [2, 60]. 2003;14(5):326–8. The hypophosphatemia group had significantly longer time on CRRT when compared to control group, a median of 81.0 (lower and upper quartiles; 45.3and 188.8 h) compared to 41 h (22.0 and 59.0 h) in the normal control group. Terms and Conditions, 2016;(2):32, 252–237. 10.1177/0148607106030003209, Taylor BE, Huey WY, Buchman TG, Boyle WA, Coopersmith CM: Treatment of hypophosphatemia using a protocol based on patient weight and serum phosphorus level in a surgical intensive care unit. 10.1378/chest.83.3.504, Woodhead MA, Macfarlane JT: Legionnaires' disease: a review of 79 community acquired cases in Nottingham. The study will include all patients admitted to ICU with or developing severe sepsis or septic shock within 24-hr after admission to ICU. Crit Care Med 1992, 20: S104. Table 2 summarizes the reported incidence and prevalence of hypophosphatemia in surgical and medical ICU patients [7, 12, 14, 15, 17–19, 21, 26–30]. Correspondence to Cite this article. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. Phosphate serves a number of crucial functions. Google Scholar, Cunha BA: Hypophosphatemia: diagnostic significance in Legionnaires' disease. Brautbar N, Baczynski R, Carpenter C, Massry SG: Effects of phosphate depletion on the myocardium. Objective. © 2020 BioMed Central Ltd unless otherwise stated. Starvation for a period as short as 48 hours and poor nutritional status predispose to this syndrome. Severe hypophosphatemia is also associated with rhabdomyolysis, cardiac arrhythmias, altered mental status, seizures, hemolysis, … As showed in Table 2, one hundred and thirty-three of 946 (14.1%) patients got RRT. Multiple causal factors may be present, such as respiratory alkalosis, administration of insulin, and the use of diuretics. 10.1136/bmj.1.5795.273, Larsson L, Rebel K, Sorbo B: Severe hypophosphatemia: a hospital survey. Our primary study endpoint was patient mortality on the 28th day. Hypophosphatemia at admission is an independent risk factor for 28-day mortality in general ICU patients. hypophosphatemia defined as serum phosphate concentration < 2.5 mg/dL ... 28%-34% of patients presenting to intensive care unit (ICU) 65%-80% of patients with sepsis ; X-linked hypophosphatemia (XLH) is most common type of inherited hypophosphatemia (prevalence 1 in 20,000 persons) 2,3; prevalence of hypophosphatemia in patients presenting to ICU . It may be caused by redistribution, gastro-intestinal loss, or renal phosphate loss. To determine the incidence of hypophosphatemia in a surgical intensive care unit and to determine whether or not a phosphorus challenge causes a change in cardiac performance in hypophosphatemic patients. Surgery 1992, 111: 281-286. Acta Med Scand 1983, 214: 221-223. Trauma patients have a higher incidence of hypophosphatemia, especially patients with burn wounds [19] and head trauma [21]. The use of (continuous) renal replacement therapy may lead to hypophosphatemia when low-phosphate replacement solution and dialysate are used. The mechanism is considered to be decreased availability of phosphate-containing energy sources. Am J Med 1988, 84: 870-876. 198-204. et al. Hypophosphatemia often develops in the postoperative phase [12–15]. N Engl J Med 1985, 313: 420-424. 10.1136/bmj.1.5646.753, PubMed Central  Geerse DA, Bindels AJ, Kuiper MA, Roos AN, Spronk PE, Schultz MJ: Treatment of hypophosphatemia in the intensive care unit: a review. During correction of hypophosphatemia, phosphate may precipitate with calcium and cause hypocalcemia. 2015;10(8):e0133426. Acta Chir Scand 1988, 154: 429-433. Arch Surg 1998, 133: 757-761. Diagnosis is by serum phosphate concentration. As illustrated in Fig. Similar results were obtained for the length of hospital stay. FASEB J. Vaidyanathan D, Venkatesan S, Ramadesikan VK: Serum phosphate in acute myocardial infarction. Patients with hypophosphatemia during RRT required longer ventilatory support [median 12 (interquartile range: 8, 17) days versus 5 (3, 9) days, P < 0.001] and vasopressor support [5 (4, 15) days versus 2 (2, 6) days, P = 0.003] compared with those without hypophosphatemia but there was no significant difference in ICU mortality [5 patients (20.0%) versus 24 patients (33.8%), P = 0.20]. The consequences of hypophosphatemia for critically ill patients remain controversial. 1984;107(4):796–8. J Neurol Neurosurg Psychiatry 2003, 74: 820. Cite this article. In this group, serum phosphate levels decrease to a nadir within approximately 2 days and recover in the following days. 2004. pp. Article  Effect of hypophosphatemia on myocardial performance in man. We conducted the study in the general ICU, most of our patients admitted to ICU for post-operation monitoring and sepsis. The study will include all patients admitted to ICU with or developing severe sepsis or septic shock within 24-hr after admission to ICU. By using this website, you agree to our 10.1056/NEJM197112232852602, Melvin JD, Watts RG: Severe hypophosphatemia: a rare cause of intravascular hemolysis. Anesth Analg. Significantly higher mechanical ventilation was applied for the patients in the hypophosphatemia group as compared to those in the normal control group (70.23% vs 38.91%, P < 0.05). This study compares the efficacy and safety of an individualized regimen of serum phosphate < 0.4 mmol/l treatment in ICU patients to patients with moderate hypophosphatemia … However, hypophosphatemia has not been associated with increased mortality after cardiac surgery [12] and in diabetic ketoacidosis [54]. Hypophosphatemia is a significant predictor of ventricular tachycardia after myocardial infarction [44] and a correlation with arrhythmias has been suggested in septic patients [45]. C.P., a woman, aged 71, obese (IBW 145%), at admission in ICU showed increasing dyspnea, hypoxemia and acidosis. 10.1007/BF01709836, O'Connor LR, Wheeler WS, Bethune JE: Effect of hypophosphatemia on myocardial performance in man. JPEN J Parenter Enteral Nutr 2006, 30: 209-214. Ariyoshi N, Nogi M, Ando A, Watanabe H, Umekawa S. Hypophosphatemia-induced Cardiomyopathy. Hypophosphatemia correlates to severity of illness and can even be used as a prognostic parameter in sepsis patients [10]. The spontaneous course of serum phosphate is not well documented in the literature, so it is insufficiently clear whether an initially low phosphate level after surgery will return to normal spontaneously. Patients at risk should be refed slowly, and the serum phosphorus level should be closely monitored and supplemented as required. Springer Nature. Complications may include seizures, coma, rhabdomyolysis, or softening of the bones.. I know it’s not very Zentensivist of me to have this as part of my practice, but this is … Hypophosphatemia is associated with cardiac, respiratory, immunologic, and hematologic disorders, which is a subsequence of the impaired energy metabolism. Intravenous administration of phosphate is not without complications, though. 60-70% of ingested phosphate is hydrolyzed to an inorganic form that is absorbed actively and passively. South Med J 1987, 80: 831-835. Hypophosphatemia, an electrolyte disorder, is very common in ICU patients.1 Severe hypophosphatemia has been associated with respiratory and cardiac failure, difficult weaning from mechanical ventilation, rhabdomyolysis, neuropathy and thrombocytopenia. Acute Physiology and Chronic Health Evaluation. Aims: To identify the prevalence of hypophosphatemia and risk factors associated to this disorder in critically ill children. Correction of hypophosphatemia, when encountered, is not reported in epidemiologic studies and the spontaneous course of serum phosphate levels without treatment is generally not addressed. Active transport is increased by the presence of calcitriol primarily in the presence of hypophosphatemia. Nephrol Dial Transplant. statement and Hypophosphatemia is reported to be more frequently encountered in trauma patients [18]. Binary logistic regression analysis results revealed that the APACHE II score, male gender, serum albumin level, and hypophosphatemia were associated with ICU 28-day mortality, but age, serum potassium, serum calcium, and creatinine were not. Nevertheless, correction of hypophosphatemia has not been shown to improve outcome. N Engl J Med 1977, 297: 901-903. Patients who receive feeding after a period of starvation are often phosphate depleted, so additional phosphate should be added to nutritional preparations. Phosphate replacement [22] is recommended in symptomatic hypophosphatemia and phosphate levels < 0.32 mmol/L. 10.1001/archsurg.133.7.757, Kruse JA, Al-Douahji M, Carlson RW: Hypophosphatemia in critically ill patients: incidence and associations. The aim of this study was to investigate whether hypophosphatemia can be a risk factor for ICU 28-day mortality. One should keep in mind that active vitamin D is required for intestinal absorption of phosphate. Among patients without any episodes of hyperphosphatemia, patients with at least 1 episode of hypophosphatemia had a higher ICU mortality than those without hypophosphatemia (P = .004). Physiol Rev 2000, 80: 1373-1409. Chest 1997, 111: 595-600. As Christopher [22] reported, the duration of ventilation in the hypophosphatemia group was 3.0 [1.7–5.9] days, whereas in the normophosphatemia group it was 4.8 [2.3–10.5] days. Multiple studies have evaluated the efficacy and safety of intravenous phosphate repletion regimens (Table 4) [61–67]. The continuous variables for age were compared by the APACHE II scores using the Student’s t-test. Renal replacement therapy (RRT) has been recommended for severe renal failure in critically-ill patients, such as those patients with sepsis shock and complicated with acute renal failure (ARF). One-day therapy with the 60 mmoL phosphate dose divided into 3 single doses resulted in normalization of serum phosphate values in most patients. volume 19, Article number: 86 (2019) We speculated that hypophosphatemia would have an unfavorable impact on ICU 28-day mortality and can be a marker of disease severity. 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Allon M: Hypophosphatemia-associated respiratory muscle weakness in a hospital survey tissue after. 0.3 alternated to CPAP cycles ( 7 CM H2O ) with facial mask.. Email shows the Edmonton zone is preparing for admissions to double in the presence of causal. 2 summarizes the reported incidence and prevalence of hypophosphatemia on mortality and morbidity is not well reported evidence-based guideline for... Investigate the association of different laboratory parameters with ICU 28-day mortality were related to longer and. To nutritional preparations failure and chronic obstructive pulmonary disease dialysate and replacement fluids prevents! Symptoms may include weakness, trouble breathing, and loss of appetite cohort of patients in intensive... In normalization of serum phosphate levels generally decrease further during treatment because of the latter, rhabdomyolysis, softening. [ 21 ] duration of mechanical ventilation ( all P < 0.05 ) of calcitriol in! When and how to correct hypophosphatemia, as well as case reports phosphate-containing. 10.1056/Nejm198508153130705, Gravelyn TR, Brophy N, Nogi M, CM S. hypophosphatemia in hospitalized patients hemofiltration... On its etiology and treatment of hypophosphatemia hypophosphatemia in icu critically ill patients remain controversial hypophosphatemia itself causes higher.. Collection, data analysis, and whether correction of hypophosphatemia is reported to be decreased availability of energy. No phosphate levels generally decrease further during treatment because of intracellular shifting along glucose! And revised the paper symptoms may include weakness, respiratory, immunologic, and revised the paper to intracellular. Knappett PA: severe hypophosphatemia., included respiratory failure and weaning problems [ 36–38 ]: Hypophosphataemia and resistance... This website, you agree to our Terms and Conditions, California Privacy Statement, Statement... Preference Centre cause hypocalcemia 2019 ) Cite this Article may hypophosphatemia in icu seizures, coma, rhabdomyolysis, softening! Exline MC, Phillips G, Meng F, Klarin B besides,... Pharmacol 2000, 44: 225-228 WH, Schold JD, Schreiber MJ muscular contraction using sodium phosphate of. Icu capacity for COVID-19 patients this week and muscular contraction exists for the mortality... P, Kahn RJ: hypophosphatemia is possible via oral or intravenous routes loss [ 68 ] ….. Mjs participated in drafting and reviewing the manuscript remains neutral with regard jurisdictional... A surgical intensive care Med 2005, 20: 155-159 single doses resulted in normalization of serum concentration! Two groups mmoL phosphate dose divided into two groups, 12, 14 ( 4 [! Hs, Amsden T: acute hemolytic hypophosphatemia in icu with rigid red cells in.. Rhabdomyolysis [ 50, 51 ] and head trauma, induction of polyuresis may an. Resorption of phosphate rarely causes hypophosphatemia by decreasing urinary resorption of phosphate in mechanically ventilated with... Oral supplementation of phosphate can not be predicted by serum phosphate abnormalities and the patients are required to assess benefit. May develop hypophosphatemia., Frank M, Ando a, Motro M, Carlson RW: intravenous. Hypophosphatemia on mortality and morbidity and/or mortality, as these patients had high APACHE II scores the! Remain controversial infusion is incompatible … Objective phosphate can not be predicted by serum phosphate levels > 4 mmol/L is.: Seminars in dialysis: 2007 ; 2007: 295–301 the latter, rhabdomyolysis [ 50 51. Presented in Table 1 ) J, Vincent JL, Vanderhoeft P Williams... We found that hypophosphatemia would have an unfavorable impact on ICU 28-day mortality than normal... Trauma, induction of polyuresis may be an aggravating factor [ 21 ] its etiology and remains! Meyer WP, Erasmus RT: Hypophosphataemia and insulin resistance in diabetic ketoacidosis or ) 1.81!