• Chinh D Nguyen, Haustine P Panganiban, Timothy Fazio, Amalia Karahalios, Melissa J Ankravs, Christopher M MacIsaac, Thomas Rechnitzer, Lucy Arno, An Tran-Duy, Scott McAlister, Ali AbdelhamidYasmineYDepartment of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia.Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia., and Adam M Deane.
• Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia.
• Crit. Care Med. 2024 Jul 1; 52 (7): 105410641054-1064.

ObjectivesHypophosphatemia occurs frequently. Enteral, rather than IV, phosphate replacement may reduce fluid replacement, cost, and waste.DesignProspective, randomized, parallel group, noninferiority clinical trial.SettingSingle center, 42-bed state trauma, medical and surgical ICUs, from April 20, 2022, to July 1, 2022.PatientsPatients with serum phosphate concentration between 0.3 and 0.75 mmol/L.InterventionsWe randomized patients to either enteral or IV phosphate replacement using electronic medical record-embedded program.Measurement And Main ResultsOur primary outcome was serum phosphate at 24 hours with a noninferiority margin of 0.2 mmol/L. Secondary outcomes included cost savings and environmental waste reduction and additional IV fluid administered. The modified intention-to-treat cohort comprised 131 patients. Baseline phosphate concentrations were similar between the two groups. At 24 hours, mean ( sd ) serum phosphate concentration were enteral 0.89 mmol/L (0.24 mmol/L) and IV 0.82 mmol/L (0.28 mmol/L). This difference was noninferior at the margin of 0.2 mmol/L (difference, 0.07 mmol/L; 95% CI, -0.02 to 0.17 mmol/L). When assigned IV replacement, patients received 408 mL (372 mL) of solvent IV fluid. Compared with IV replacement, the mean cost per patient was ten-fold less with enteral replacement ($3.7 [$4.0] vs. IV: $37.7 [$31.4]; difference = $34.0 [95% CI, $26.3-$41.7]) and weight of waste was less (7.7 g [8.3 g] vs. 217 g [169 g]; difference = 209 g [95% CI, 168-250 g]). C O2 emissions were 60-fold less for comparable phosphate replacement (enteral: 2 g producing 14.2 g and 20 mmol of potassium dihydrogen phosphate producing 843 g of C O2 equivalents).ConclusionsEnteral phosphate replacement in ICU is noninferior to IV replacement at a margin of 0.2 mmol/L but leads to a substantial reduction in cost and waste.Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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