Can I administer a banana bag by combining thiamine and folic acid in a 100ml bag of Normal Saline (NS) or Dextrose 5% in Water (D5W) over 30 minutes, followed by a 1L bag of Normal Saline (NS) or Dextrose 5% in Water (D5W) containing magnesium sulfate and Infuvite (multivitamin component)?

From the Guidelines

No, you should not administer a banana bag by combining components separately as described, as it may lead to compatibility issues, improper dosing, or administration errors, and instead, a traditional banana bag should be prepared by a pharmacist according to standardized protocols, containing thiamine, folic acid, multivitamins, and magnesium sulfate in 1L of D5W or NS, administered over several hours. The traditional banana bag contains thiamine (100 mg), folic acid (1 mg), multivitamins (Infuvite), and magnesium sulfate (1-2 g) in 1L of D5W or NS, administered over several hours (typically 4-8 hours) 1. Splitting the components as suggested could lead to compatibility issues, improper dosing, or administration errors. The slow infusion rate is important for patient tolerance, especially for magnesium which can cause flushing, hypotension, or pain if infused too quickly, as noted in the guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. Additionally, some components may be incompatible when mixed improperly. Banana bags are typically used for patients with alcohol use disorder to correct nutritional deficiencies and should be administered according to established medical protocols under appropriate supervision.

Some key points to consider when administering a banana bag include:

• The importance of using a standardized protocol for preparation to avoid errors
• The need for slow infusion to prevent adverse effects, particularly with magnesium sulfate
• The recommendation for folic acid dosage, which is advised to be 400- to 800-μg per day as part of a complete multivitamin and mineral supplement 1
• The potential for incompatibility between components if not mixed correctly, highlighting the need for pharmacist preparation.

Given the potential risks associated with improper preparation and administration, it is crucial to follow established protocols for banana bag preparation and administration to ensure patient safety and efficacy.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Dosage of magnesium sulfate must be carefully adjusted according to individual requirements and response, and administration of the drug should be discontinued as soon as the desired effect is obtained. Solutions for IV infusion must be diluted to a concentration of 20% or less prior to administration. The diluents commonly used are 5% Dextrose Injection, USP and 0. 9% Sodium Chloride Injection, USP. Incompatibilities Magnesium sulfate in solution may result in a precipitate formation when mixed with solutions containing:

The FDA drug label does not answer the question.

From the Research

Administration of Banana Bag

• The proposed method of administering a banana bag by combining thiamine and folic acid in a 100ml bag of Normal Saline (NS) or Dextrose 5% in Water (D5W) over 30 minutes, followed by a 1L bag of Normal Saline (NS) or Dextrose 5% in Water (D5W) containing magnesium sulfate and Infuvite, may not be the most effective approach 2.
• Thiamine is unstable in solutions containing bisulfite, which may be present in some infusion solutions 3, 4.
• The stability of thiamine in total parenteral nutrition mixtures stored in EVA and multi-layered bags has been investigated, and results indicate that thiamine is unstable in mixtures containing metabisulphite-containing amino acid infusions 4.
• A study on the treatment of cognitive impairment in maintenance haemodialysis patients suggests that thiamine and folic acid supplementation may improve cognitive function 5.
• In patients with malnutrition, thiamin replacement should be given before starting nutrition to prevent re-feeding syndrome, and energy intake should be gradually increased 6.
• The recommended formula for routine supplementation during the first day of admission for patients with a chronic alcohol use disorder admitted to the ICU includes 200-500 mg IV thiamine every 8 hours, 64 mg/kg magnesium sulfate, and 400-1,000 μg IV folate 2.

Key Considerations

• Thiamine deficiency may develop in malnourished patients, and replacement therapy should be given before starting nutrition 6.
• The banana bag approach may not optimize delivery of thiamine to the central nervous system 2.
• Folic acid and magnesium may also merit supplementation, although the available data do not allow for as strong a recommendation as for prescribing thiamine 2.
• There is no available evidence supporting the prescription of a multivitamin 2.