Position statement from International IV Nutrient Therapy for Professionals

http://ivnutritionaltherapy.com/

Our position as IV educators is that we recommend full compliance with CDC and USP 797 guidelines; Local or profession based practices that deviate from these standards (i.e. “that is not how I was trained” or “no one I know follows those” …) are not acceptable defense when an adverse event occurs and never supersede USP and CDC guidelines.

Below are the guidelines as prepared by the agencies mentioned. After each section comment regarding the guideline germane to IV Nutrient Therapy practices is made.

Single Dose Vials

Source: http://www.cdc.gov/injectionsafety/PDF/CDC-SDV-Position05022012.pdf
CDC’s Position: Protect Patients Against Preventable Harm from Improper Use of Single-dose/Single-use Vials
These medications typically lack antimicrobial preservatives and can become contaminated and serve as a source of infection when they are used inappropriately.
The Centers for Disease Control and Prevention’s guidelines call for medications labeled as “single dose” or “single use” to be used for only one patient. This practice protects patients from life-threatening infections that occur when medications get contaminated from unsafe use. Concerns have been raised about whether these guidelines and related policies contribute to drug shortages and increased medical costs to healthcare providers. CDC recognizes the problem of drug shortages; however, such shortages are a result of manufacturing, shipping, and other issues unrelated to the above guidelines (http://www.fda.gov/DrugShortageReport ).

CDC ’s priority is protecting patients from harm. CDC routinely investigates and is apprised of infectious disease outbreaks involving single-dose/single-use vials being used for multiple patients. These outbreaks cause extensive harm to patients, and they are associated with significant healthcare and legal expenses. Therefore, CDC continues to strongly support its current policies regarding single-dose/single-use vials. It is imperative that drug shortages and drug waste concerns are dealt with appropriately and do not lead to unsafe medical practices that impose increased disease risk on patients.

In times of critical need, contents from unopened single–dose ⁄ single–use vials can be repackaged for multiple patients. However, this should only be performed by qualified healthcare personnel in accordance with standards in United States Pharmacopeia General Chapter ‹797› Pharmaceutical Compounding — Sterile Preparations. Following the USP standards is imperative, as medication contamination and patient harm can occur when repackaging (e.g. splitting doses) is not done properly.*

*Clarification for IV nutrient therapy practice
Medical practices using preservative free drugs/nutrients are advised to ask their compounding pharmacy to repackage commonly used products in unit dose vials in order to reduce waste, in accordance with the above standards.

Multiple Dose Vials

Source: http://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html
A multi-dose vial is a vial of liquid medication intended for parenteral administration (injection or infusion) that contains more than one dose of medication. Multi-dose vials are labeled as such by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. The preservative has no effect on viruses and does not protect against contamination when healthcare personnel fail to follow safe injection practices.

Multi-dose vials should be dedicated to a single patient whenever possible.**
If multi-dose vials must be used for more than one patient, they should not be kept or accessed in the immediate patient treatment area. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients. If a multi-dose vial enters the immediate patient treatment area, it should be dedicated to that patient only and discarded after use. Examples of the immediate patient treatment area include patient rooms or bays, and operating rooms.
 
Medication vials should always be discarded whenever sterility is compromised or questionable.
In addition, the United States Pharmacopeia (USP) General Chapter 797 recommends the following for multi-dose vials of sterile pharmaceuticals:
• If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
• If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer’s expiration date.
 
**Clarification for IV nutrient therapy practice
A multi-dose vial kept exclusively in the clean IV preparation area may be used for multiple (different) patient infusions. Vial adaptor spikes with needless access are recommended as a further measure of preventing contamination. If a vial is used in a patient treatment area the above standards must be followed.

A prospective patient called my office and inquired about intramuscular vitamin B12 injections. She stated that she had undergone an ileectomy and required B12 injections since that time. She had heard from a friend that methylcobalamin may be more beneficial for her than the “regular kind” she was using. After a rather pointed question and answer period I found that her “regular kind” was cyanocobalamin, 30 mL vial, 1000 micrograms per mL and she was injecting 2 mL once a month. She stated that the vial was stored at room temperature and was used until gone, which typically took over a year. She admitted that effectiveness seemed less when the vial was getting empty, but said that no infection occurred at injection sites.

There were two important issues the patient brought up: how long can a multi-dose vial maintain sterility after multiple entries, and what happens to drug potency after prolonged exposure to variable room temperature and air? Sterility is the main safety issue and prevention of iatrogenic infection is a primary objective of any physician.

The current practice guideline for multiple dose vials is that they may be used for one month after first entry. Storage recommendations depend on what type of drug is involved. Cyanocobalamin is usually stored at room temperature, whereas other B-vitamins, methyl and hydroxo cobalamins, and minerals are normally stored in the refrigerator after first entry.

What is the best procedure to prevent infection when using parenteral drugs? Every check on the following list needs to be followed with every use of the drug. Note: this list covers correct drug use only. It does not address administration.

1. Confirm the drug name
2. Check the expiration date
3. Check for clarity if the drug is a solution. Suspensions may be cloudy. Examine for precipitates
4. Clean the top of the vial well with IPA or other approved antiseptic
5. Enter the vial with a new sterile needle attached to an unused sterile syringe, introduce a volume of air that matches the drug volume and withdraw the drug
6. Store appropriately

Another method to decrease contamination of frequently used vials is to use a needleless vial adapter. Vial adapters are inserted into a vial once, and stay in place until the vial is empty or it outdates. Air does not need to be pushed into the vial because the adapter has a filter that allows air entry as the drug is withdrawn. Here are two different brands:

This one is a Codan C350N vial adapter with Swan Lock needless entry.

And here is a B Braun Ultrasite adapter

I ordered her some methylcoblamin and instructed her in its proper and safe application.

In the recent Volume 16 online supplement of Alternative Medicine Review in an article titled ” The Concern about B-Vitamins Affecting the Oxidant Effect of Intravenous Ascorbate for Malignancy,” Lamson, et al. presented a summary of in vitro research that indicates B-vitamins interfere with the generation of hydrogen peroxide.[ii] From the paper summary:

“… the anti-tumor effect of high concentration ascorbate performs its function in the interstitial fluid beyond the blood circulation. Ascorbate is converted to superoxide, which proceeds to the hydrogen peroxide believed to be the active agent. Most of the B-vitamins can quench superoxide under some conditions and would presumably lower the concentration of hydrogen peroxide available for anti-malignant action. Therefore a caution seems appropriate against the inclusion of B-vitamins with intravenous ascorbate aimed at tumor cell cytotoxicity. However, this general recommendation based on chemistry cited above needs the support of in vivo studies for certainty.”

Within the last few years the Bastyr University Integrative Oncology Research Center has been performing clinical research on HDIVC, among other projects. Dr Paul Anderson, IVNTP instructor, headed up an analysis regarding the effect of HDIVC infusions on electrolyte balance. The upshot being that we now recommend using only the chloride salts of calcium, magnesium and potassium to balance the large sodium load resulting from the ascorbic acid. Stock ascorbic acid has a pH of about 2, which is much too acid for an IV infusion; the manufacturer buffers the ascorbic acid with sodium hydroxide and sodium bicarbonate, resulting in sodium ascorbate at a pH tolerable for intravenous applications but at the cost of a high sodium concentration. Chloride mineral salts balance the sodium load resulting in less blood electrolyte imbalance. Our two day Clinical Applications and Advanced Topics of IV Nutrient Therapies seminar covers the safe and effective use of HDIVC and dosing of the chloride mineral salts in detail.

[i] Pharmacologic ascorbic acid concentrations selectively kill cancer cells: Action as a pro-drug to deliver hydrogen peroxide to tissues. Proceedings of the National Academy of Sciences2005.102;38:13604-13609

[ii] Lamson DW, Ochi M, Hetherington J. The Concern about B-Vitamins Affecting the Oxidant Effect of Intravenous Ascorbate for Malignancy. Alternative Medicine Review. Volume 16 supplement (ePub), 2011.

Arterial cannulation is a commonly performed procedure in the management of patients who are critically ill. Approximately 8 million arterial catheters are placed yearly in the United States.(1)An indwelling arterial catheter allows for continuous blood pressure (BP) monitoring, frequent blood sampling, and arterial blood gas measurement.

When a physician performs IV infusions on a regular basis for many years they may encounter situations that they have not previously experienced. I had been treating an 84 year old male for cancer with high dose vitamin C for five months; infusions have been done once or twice weekly during this time and venous access had never been a problem. The patient came in for another infusion, which turned out to be an interesting experience for me. After preliminaries such as vital signs were completed, I attempted to insert a catheter (24 gauge by 3/4 inch) into the Dorsal Metacarpal Vein of his right hand; this was unsuccessful. I then attempted the Accessory Cephalic Vein in his right forearm; no go. I asked the patient about his hydration status and he claimed that he had been drinking extra water prior to his appointment as instructed. I then moved to the left antecubital fossa and palpated a vein I have accessed before; there was no palpable pulsation. I inserted the catheter but did not see returns in the flash chamber; the catheter was redirected with similar results. I then advanced the catheter to the hub and noted blood returns, at which point I removed the tourniquet, occluded the catheter tip with digital pressure, removed the stylet, and attached the IV tubing. As soon as digital pressure was removed from the catheter tip, bright red blood entered the IV tubing in a pulsatile  manner.

I thought but did not verbalize “woops.” I obtained several gauze sponges from the chairside table, applied them to the puncture site, and removed the catheter without incident. I told the patient that the site was unsuitable. I then held direct pressure over the site for 10 minutes, during which time I reassured the patient, telling him that I had accessed an artery and that all was well. After 10 minutes I checked the site and did not see any swelling or hematoma. Pressure was re-applied for another 5 minutes after which a pressure bandage was placed. Vital signs were taken and the patient was instructed to call me if he noticed any pain or swelling at the site. He was discharged from the clinic feeling well. I called him at home and told him to examine the site; it was free of swelling or discoloration. I reminded him to call me if anything unusual happened at the site. A phone call the next morning revealed no problems.

Post incident analysis indicated that it was most likely the Ulnar artery that was punctured just distal from its bifurcation with its parent artery, the Brachial. When I was working as a medical technologist I would occasionally be asked to collect arterial blood. The radial artery was the site of choice, and I performed this procedure several times over the years without incident. Just be aware that more superficial arteries are accessible with even a short catheter, and be prepared to treat the arterial puncture appropriately.

Here is an interesting case of inadvertent carotid artery cannulation and the ensuing complications. This patient was dehydrated so venous access was difficult.(2) Paste the reference link into your browser

References

1. Scheer B, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care. Jun 2002;6(3):199-204.

2. Nair S, et al. A case of accidental carotid artery cannulation in a patient for Hemofilter: complication and management. BJMP 2009:2(3)57-58. http://www.bjmp.org/content/case-accidental-carotid-artery-cannulation-patient-hemofilter-complication-and-management Accessed 8.8.11.

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I have a patient who obtains all of the injectable nutrients for their protocol from Switzerland, as the primary care giver for their health complaint has a large clinic there. The IV vitamin C is manufactured by Laboratorium Dr G Bichsel AG in Interlaken. The reason I mention this is so that if you need to use this product, you can be prepared for possible “pressure buildup” in the vial. I have used this product several times in the past and noted a tendency for pressurization; it is a 15% solution of vitamin C in a 50 mL vial.

I have started using a protective apron when setting up IV solutions to protect my clothing from drops of nutrients that invariably find their way onto my pants legs, later to dry in nice white crystalline deposits. Today I was very glad to have the apron. I use a 35 mL syringe with an 18 gauge Admix needle to draw up vitamin C and when I entered the vial the pressure buildup in the vial was sufficient to push the plunger all the way to the 35 mL mark, where it normally stops due to syringe design. This time the madly foaming liquid pushed the plunger out of the barrel and all of the vitamin C ended up on the front of my apron and the floor. I took it quite well, no cussing, as the patient was in the adjacent room.  So if you use this vitamin C in the future, be aware that pressure buildup may be more than you expect. My apron is normally a nice consistent light blue.

30 March 2011

Alabama bacteria outbreak: US officials join probe

The culprit: Serratia bacteria tend to spread in hospital patients’ respiratory and urinary tracts

Federal officials are investigating an outbreak of a bacterial blood infection that killed nine patients and made 10 others ill in Alabama hospitals.

The victims, already seriously ill, were stricken with Serratia marcescens bacteraemia this month.

All had been given an intravenous nutritional product manufactured by an Alabama company, which recalled all of its products following the outbreak.

But an Alabama health official warned the outbreak’s origin remained unclear.

‘Contained’

The stricken patients at six Alabama hospitals were all taking an intravenous nutritional product manufactured by a single pharmacy, Meds IV, the state Department of Public Health said in a Tuesday statement.

Upon learning of the outbreak, the company ceased production and on 24 March recalled all of its intravenous products, the department said.

“We’re not expecting any additional cases,” Dr Mary McIntyre, of the department’s bureau of communicable disease, told the BBC. “It has been contained.”

But she cautioned that investigators had not directly linked the outbreak to the nutritional product, called TPN (total parenteral nutrition).

She said the federal Centers for Disease Control and Prevention, and the Food and Drug Administration had joined state authorities in the investigation.

I would suggest reviewing the points made in the last posting as well as IV seminar notes regarding safety!

During our seminars we constantly stress the importance of avoiding contamination of intravenous solutions: Please note that exact procedures for handling IV fluids are covered in our seminars and professional forums; the following list is for illustrative purposes only.

• Make sure carrier solutions are both in date and clear. Clear means no visual cloudiness or particulates
• Clean the add port or vial tops correctly before every entry
• Check both the drug name and solution clarity every time you withdraw from a vial
• Check the date on vials each time you use them. Date all vials after first entry and do not use them past the allowed time for either a single or multiple dose vial.
• Immediately discard any carrier solution or vial that shows signs of contamination

The critical importance of avoiding contamination is brought to the fore by this unfortunate incident in India.

24 February 2011 : Tainted IV fluid kills 13 pregnant women in India

Health authorities in India’s Rajasthan state are investigating allegations that 13 pregnant women died after they were given infected intravenous (IV) fluids at a government hospital.

All the deaths were reported in Jodhpur city over the past 10 days.

Laboratory tests had confirmed that IV fluids supplied by a local company were “tainted”, officials said.

A police case has been registered and an investigation has begun, they said.

“The women died after severe hemorrhaging and we believe the most likely cause might be an infection after they were administered tainted IV fluids,” Umaid Hospital administrator Narendra told the BBC.

“During lab tests, we found three batches of glucose which were tainted. We have lodged a complaint with the police and strict action will be taken against the manufacturers,” he said.

India accounts for the highest number of maternal deaths in the world with tens of thousands of women dying every year due to pregnancy-related problems.

Campaigners say most of the deaths are needless and could easily be prevented if more care and attention was paid to their treatment.

The bottom line – Know your suppliers and follow good clinical practice guidelines.

Physicians caring for patients with sepsis may soon have a new safe and cost-effective treatment for this life-threatening illness. Research led by Dr. Karel Tyml and his colleagues at The University of Western Ontario and Lawson Health Research Institute have found that vitamin C can not only prevent the onset of sepsis, but can reverse the disease.

Sepsis is caused by a bacterial infection that can begin anywhere in your body. Your immune system goes into overdrive, overwhelming normal processes in your blood. The result is that small blood clots form, blocking blood flow to vital organs. This can lead to organ failure. Babies, the elderly and those with weakened immune systems are most likely to get sepsis. But even healthy people can become deathly ill from the disease.

According to Dr. Tyml, a professor at Western’s Schulich School of Medicine & Dentistry, patients with severe sepsis have a high mortality rate, nearly 40 percent, because there is no effective treatment.

“There are many facets to sepsis, but the one we have focused on for the past 10 years is the plugging of capillaries,” says Dr. Tyml. Plugged capillaries prevent oxygenation and the supply of life-supporting materials to your organ tissue and stop the removal of metabolic waste product. Plugged capillaries are seen in organs of septic patients. These organs may eventually fail, leading to multiple organ failure and death. Dr. Tyml’s lab was the first to discover this plugging by using intravital microscopy, a technique Dr. Tyml pioneered in Canada.

According to Dr. Tyml’s most recent publication, oxidative stress and the activated blood clotting pathway are the major factors responsible for the capillary plugging in sepsis. Through his research, Dr. Tyml has discovered that a single bolus of vitamin C injected early at the time of induction of sepsis, prevents capillary plugging. He has also found that a delayed bolus injection of vitamin C can reverse plugging by restoring blood flow in previously plugged capillaries.

“Our research in mice with sepsis has found that early as well as delayed injections of vitamin C improves chance of survival significantly,” explains Dr. Tyml. “Furthermore, the beneficial effect of a single bolus injection of vitamin C is long lasting and prevents capillary plugging for up to 24 hours post-injection.”

Dr. Tyml and his colleagues are eager to find appropriate support to move this research from the bench to the bedside to see if these findings translate to patients with sepsis.

The potential benefit of this treatment is substantial. “Vitamin C is cheap and safe. Previous studies have shown that it can be injected intravenously into patients with no side effects,” says Dr. Tyml. “It has the potential to significantly improve the outcome of sepsis patients world-wide. This could be especially beneficially in developing countries where sepsis is more common and expensive treatments are not affordable.”

Source:
Kathy Wallis
University of Western Ontario

IVC is also showing promise as a treatment for burns. Here is a short excerpt from http://emedicine.medscape.com/article/1277360-overview.

Vitamin C^{1, 2}

A great deal of interest exists in using antioxidants as adjuncts to resuscitation to try to minimize oxidant-mediated contributions to the inflammatory cascade. In particular, megadose vitamin C infusion during resuscitation has been studied at some length. Some animal models have demonstrated that infusion of vitamin C within 6 hours postburn can lower calculated resuscitation values by up to one half. Whether this phenomenon can be reproduced successfully in human subjects has not been clearly demonstrated.

Proponents have reached no consensus regarding the proper total dose. Some have adopted the strategy of placing up to 10 g in a liter of RL solution, infusing it at 100 mL/h (1 g/h vitamin C), and counting the volume as part of the resuscitation volume. Recently published data using an infusion of 66 mg/kg/h during the first 24 hours demonstrate a 45% decrease in the required fluid resuscitation in a small group of patients.

The safety of high-dose vitamin C has been established in humans, at least for the short-term, but this strategy is probably less safe in patients who are pregnant, those with renal failure, and those with a history of oxalate kidney stones.

1. Sakurai M, Tanaka H, Matsuda T, et al. Reduced resuscitation fluid volume for second-degree experimental burns with delayed initiation of vitamin C therapy (beginning 6 h after injury). J Surg Res. Nov 1997;73(1):24-7. [Medline].
2. Tanaka H, Matsuda T, Miyagantani Y, et al. Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration: a randomized, prospective study. Arch Surg. Mar 2000;135(3):326-31. [Medline].

Please note that both references are from Japan; perhaps there is less peer pressure to avoid non-pharmaceutical treatments in Japan, even though these treatments are safe and effective. Here is a 1992 article from the same group.

Burns. 1992 Apr;18(2):127-31.
High-dose vitamin C therapy fro extensive deep dermal burns.
Matsuda T, Tanaka H, Shimazaki S, Matsuda H, Abcarian H, Reyes H, Hanumadass M.

Abstract

We studied the haemodynamic effects of antioxidant therapy with high-dose vitamin C administration (170 mg/kg/24 h) in guinea-pigs with 70 per cent body surface area deep dermal burns. The animals were divided into three groups of six animals each. Group 1 was resuscitated with Ringer’s lactate solution according to the Parkland formula; group 2 with 25 per cent of the Parkland formula with vitamin C; and group 3 with 25 per cent of the Parkland formula without vitamin C. There were no significant differences in heart rates or in blood pressures between the groups throughout the 24-h study period. Group 3 showed significantly higher haematocrit values at 3 h postburn and thereafter as compared with those of group 2. The cardiac output values of group 2 were significantly higher than those of group 3, but equivalent to those of group 1. The water content of the burned skin in group 2 was significantly lower than that in the other groups, indicating that increased postburn capillary permeability was minimized by the administration of vitamin C. With adjuvant high-dose vitamin C administration, we were able to reduce the 24-h resuscitation fluid volume from 4 ml/kg/per cent burn to 1 ml/kg/per cent burn, while maintaining adequate cardiac output.

Here are two bullet points from an article from the Journal of Burn Care & Research July/August 2007. Burn Resuscitation by David G. Greenhalgh,

A multicenter trial to examine the role of vitamin C during burn shock resuscitation should be performed.

The last topic for investigation is to test an agent that will reduce the capillary leak that occurs during burn shock. The investigation of high dose vitamin C seems to make the most sense for the first trial.

Treatment and improvement of CVD signs, symptoms and blood parameters is multifactorial, including diet, pharmaceuticals (not covered in this article), IV and oral nutrient therapy, exercise and lifestyle. The “ sound bite” version of treatment would look like this: Most of the references will be included in our soon-to-be-published book.

Diet

Low carbohydrate, moderate protein (Clifton)(Layman), moderate good fat, whole food diet. Eliminate sugar and all foods with flour. Eliminate wheat; even if a person does not have Celiac disease, wheat often causes an innate immune response leading to gut inflammation. High carbohydrate diets are not heart healthy or beneficial to body composition. (Lasker) Moderate protein is 0.5-0.75 grams protein per pound body weight. More physical activity requires greater amounts of protein; most people are good at 0.5 grams/pound, a very active person may do better at 0.75 grams/pound. For example, a person weighing 150 pounds would require 75-113 grams protein daily (2.7 to 4 ounces protein). The RDA for protein is 0.36 grams/pound which may keep most people out of protein malnutrition, but it is not sufficient for optimal health. Meat is about 20% protein so if you are getting all your protein from meat you would need to eat about 13-20 ounces meat daily. Eggs are another good protein source. One egg provides 6.3 grams good protein or 0.2 ounces, so 2 eggs would provide about ½ ounce protein. Good sources of protein are wild game, grass fed beef, buffalo and lamb, free range chicken. Alaska salmon is good and generally free of mercury contamination. Use healthy fat (wild or pastured animal fat, butter, coconut oil, olive oil is fine to add after cooking. Eliminate grain and seed derived oils; these oils have excess omega-6 fats that contribute to inflammation. Eat low glycemic vegetables ad libitum; consume about 400  carbohydrate calories (100 grams) from non-toxic sources, these include white rice, sweet potatoes, yams and white potatoes. If visceral fat is an issue stick with vegetables and avoid the non-toxic carbohydrates until body weight normalizes.

IV Nutrient Therapy

Magnesium

IV magnesium is used successfully to prevent/convert atrial fibrillation during coronary artery bypass graft procedures. Although there was no significant difference betweengroups with respect to episodes of ventricular arrhythmias, there was asignificant decrease in the number of episodes of atrial fibrillation inthe group receiving magnesium therapy (p less than 0.02).(2) Hypomagnesemia, probably related to increased urine magnesium excretion, is an essential feature of heart failure associated with ventricular arrhythmias. IV administration of magnesium (magnesium sulfate 8 g in 250 mL of 5% glucose) over 12 hours alleviated or prevented the arrhythmias. If a patient has had recent surgery, and has impaired platelet function and co-existing bleeding disorders, large-dose IV magnesium therapy should be carefully considered, as it can inhibit platelet function in vitro and in vivo. Serum Mg < or = 1.95 mg/dL was found to be a risk factor for sudden death and for death from progressive pump failure in congestive heart failure.

There are studies showing that IV Mg can move from the vascular space (blood) to the ECF and cells over 48 hours after administration. When giving IV Mg on consecutive days lower the dose or add calcium to moderate the Mg effect; not doing so risks speed shock with typically safe doses of Mg.

Potassium (K)

IV K is administered to provide solution balance and minimal replacement. Potassium repletion for hypokalemic patients requires laboratory services (to measure electrolyte levels) and patient monitoring equipment including ECG. K infusion rates should not exceed 10 mEq/h. K is never given in an IV push.

Taurine

Taurine is a sulfur containing organic acid that is present in all cell membranes and plays a major role in the normal functioning of electrically excitable tissues. Taurine is effective for arrhythmia, cardiomyopathy, congestive heart failure, mitral valve prolapse, and cholesterol reduction. Taurine is essential to synthesize taurocholic acid, a bile salt that binds cholesterol in the gut. Taurine suppresses renin helping to break the renin-angiotensin feedback loop; this leads to lower blood pressure. Magnesium and taurine are highly complementary.

Arginine

Interest in arginine for cardiovascular disease centers on its role as a precursor to the neurotransmitter nitric oxide (NO). In fact, arginine is the sole nitrogen source for nitric oxide (NO) synthesis. NO is the lightest and smallest molecule and it helps to regulate the dilation and constriction of small blood vessels. NO synthase is inhibited by many of the toxic metals.

Carnitine

Carnitine and Taurine are both essential for cardiovascular health, and especially for vegetarians, as meat is the main food source for both nutrients. Carnitine is concentrated in the heart more than in any other organ. Carnitine has the ability to increase fat oxidation; the heart utilizes fat oxidation extensively for energy production. Carnitine is also useful to lower triglycerides. Carnitine is an important conditionally essential nutrient for the heart. Both carnitine and taurine are synthesized, not derived from animal sources, so are suitable for vegans.

Proline

Proline is very important for collagen production and reducing the loss of collagen during the aging process. It helps maintain and strengthen the heart muscle. Proline is contraindicated in depression or seizures. Linus Pauling suggested that a mixture of vitamin C, lysine and proline could prevent or treat CVD.

Phosphatidylcholine (PC)

PC is the most abundant phospholipid in animal and plants, often amounting to almost 50% of the total, and is the main structural component of cell membrane bilayers. It makes up a very high proportion of the outer leaflet of the membrane. PC is also the principal phospholipid circulating in plasma, where it is an integral component of lipoproteins, especially HDL. Most studies on PC have focused on its healing effect on the liver, where it restores biological function in conditions such as cirrhosis. Its use in CVD centers on its possible effect of raising HDL cholesterol.

PC infusions can be alternated with chelating agents such as EDTA; the most beneficial treatment ratio has not been studied. A Russion study showed that lipostabil forte (oral PC product) improved the functional activity of high-density lipoproteins in reverse cholesterol transport. (Ozerova) PC has also been shown to improve the removal of cholesterol from vascular plaques. (Chung)

Selected complementary oral treatments

Niacin

Niacin is currently the most effective drug for lowering LDL-C and raising HDL-C. Niacin appears to have a beneficial effect on LDL-P. (Haseeb) Sustained release niacin taken at bedtime decreases adverse effects that may occur with daytime dosing. Starting dose is 500 mg and the dose is incremented over 6 weeks to a total dose of 1500 mg. Some patients may require dosing as high as 3000 mg. Follow liver function tests monthly during initial dosing period and lipid panels every 3-6 months.

Vitamin D

Low 25-hydroxyvitamin D levels have been associated with the cardiovascular disease risk factors of hypertension, obesity, diabetes mellitus and the metabolic syndrome, as well as cardiovascular disease events including stroke and congestive heart failure. (Michos) (Wang)

Despite substantial clinical evidence linking vitamin D deficiency with increased cardiovascular risk, it remains to be established whether this represents a causal association. Further study is needed with prospective, randomized controlled trials before vitamin D supplementation can be routinely recommended for the primary or secondary prevention of cardiovascular disease. (Pipe) Conservative save doses of vitamin D3 are in the 2000 IU range for adults. Measure vitamin D levels (25-OH vitamin D) every six months; most clinical studies in a variety of health areas point toward a blood level of vitamin D that is between 90 to 100 nmol/L, or 35 to 40 ng/mL, for preventive health. (Moyad) Physicians acquainted with nutrition will generally recommend repletion sufficient to obtain 25-OH vitamin D blood levels of 50-80 ng/mL.

Co-Enzyme Q10

Co-enzyme Q10, 120 mg daily. Q-gel is a quality brand that is well absorbed. Many cheap CoQ10 supplements do not absorb into the bloodstream well.

Research has shown that orally administered CoQl0 can improve functioning of myocardial tissue, strengthening the heart’s contractions and making it beat more strongly (positive inotropic effect) and more regularly (anti-arrhythmia effect). CoQ10 also acts as an antioxidant to control free radicals produced during cardiac interventions (including angioplasty, thrombolysis, and surgery).

Accordingly CoQl0 has been used in the treatment of different heart disorders that include arrhythmias related to primary cardiomyopathies or secondary forms of heart failure. A 1998 study observed patients with acute myocardial infarction. For 28 days one group received 120 mg of CoQ10 and the other group received a placebo. After treatment, total arrhythmias were 9.5% in the CoQ10 group compared to 25.3% in the placebo group. CoQ10 produced a significant reduction in angina pectoris and left ventricular dysfunction. Non-fatal infarction and cardiac deaths also were significantly lower in the CoQ10 group. This shows that CoQ10 helps prevent potentially life-threatening dysrhythmias during the immediate period following a myocardial infarction. This is the period of time when arrhythmia has the greatest likelihood of causing death.

Fish oil

One of the triggers for the formation of atherosclerotic plaques in arteries is inflammation, and a significant contributor the inflammation is the relative excess of omega-6 oils in the diets of most people. An ideal omega-6:omega-3 ratio has been postulated to be in the range of 1:1 to 4:1; the ratio of many Americans has been estimated to be as high as 25:1 and this will definitely contribute to a pro-inflammatory state. Patients should be advised to avoid the commercial seed oils including safflower, soy, corn, Canola and peanut. Fish oil must be fresh and unoxidized; rancid oil does more damage than benefit. An average dose is 5 mL daily.

References:

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Haseeb Jafri, Richard H Karas, Jeffrey T Kuvin. Effects of Niacin on LDL Particle Number: Niacin & LDL-P. Clin Lipidology. 2009;4(5):565-571

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Edited by Andrew Pipe.  Vitamin D and cardiovascular disease risk: emerging evidence. Current Opinion in Cardiology: September 2010 – Volume 25 – Issue 5 – p 513–517.

Moyad MA.  Vitamin D: A Rapid Review. Dermatology Nursing. 2009;21(1).