Parenteral Nutrition Shortages, Like Drug Shortages, Affect Clinical Options

Author: Lynne Peeples

Anesthesiology News

Nutrition shortages are not only a headache for health care organizations; the resultant rationing also may put patients’ health at risk, according to research presented at the American Society for Parenteral and Enteral Nutrition (ASPEN) 2019 Nutrition Science and Practice Conference.

“We’re dealing with drug shortages every day in our health system,” said investigator David Evans, MD, a trauma surgeon at the Ohio State University Wexner Medical Center, in Columbus. “We all know that if we aren’t able to deliver adequate nutrition over time, then it is going to result in worse outcomes.”

Yet the literature had been lacking data on any direct connections between drug shortages and nutrition deficits. Dr. Evans and his colleagues aimed to fill that void.

After Hurricane Maria struck Puerto Rico in September 2017, hospitals across the United States began to face major shortages of IV fluids, amino acids and other critical components of parenteral nutrition (PN). Wexner Medical Center was no exception. “This was our first crisis where we had to manage supply on a daily basis,” Dr. Evans said.

“Protein or amino acids are crucial for healing of our surgical patients and ensuring they are able to mount an adequate immune response to infection and other stressors they experience while in the hospital, and to heal their wounds,” said Dr. Evans, citing a joint consensus statement on nutrition and enhanced recovery after surgery (Anesth Analg 2018;126[6]:1874-1882).

To preserve supply after Hurricane Maria, Dr. Evans and his team used a variety of strategies, such as restricting order entry and review to pharmacists with expertise in PN. For example, they could ensure that the total amino acids dispensed for the day would not require spiking a new bag to get 50 cm³ more and then wasting the rest of that bag. “We tried to maximize use of our supply and minimize its wastage,” he said.

In addition, they began using premixed products such as Baxter’s Clinimix (amino acids in dextrose), as well as Fresenius Kabi’s Smoflipid (lipid injectable emulsion). The latter allowed them to shift more calories as fat to replace some of the deficit in amino acids. The team also reduced the total goal protein for some patients.

Phil Ayers, PharmD, the chief of clinical pharmacy services at Mississippi Baptist Medical Center, in Jackson, and chair of the ASPEN Parenteral Nutrition Safety Committee, said such efforts underscore the valuable role that pharmacists can play in determining whether adequate macronutrients and micronutrients are being provided to PN patients. And it is “imperative” that pharmacists communicate any shortages and appropriate management strategies to everyone involved in the care of PN patients, Dr. Ayers said. He recommended referencing ASPEN’s Parenteral Nutrition Safety Toolkit in such communications.

Jay Mirtallo, MS, RPh, a clinical practice specialist for ASPEN, praised the Ohio State researchers for their work. “I don’t think enough people in pharmacy have gone back like they have,” and reflected on the effects of prescribing changes made during PN shortages, he said. “Maybe [the result of such work] would lead you to make a different choice” when considering alternative agents during the next PN shortage, he noted. “Because we know shortages are going to be part of our life.”

Mirtallo added that although the Ohio State study focused primarily on managing PN shortages during patients’ hospital stays, caloric and protein balance is perhaps even more essential for a patient’s long-term recovery post-discharge. Younger patients are particularly vulnerable, he noted: “A deficiency can cause permanent changes” in children.

A Generation Gap?

Because drug shortages have been going on for so long, Mirtallo warned that a generation of clinicians caring for patients may have never had the ability to dose PN to goal. He said this had motivated ASPEN’s January 2019 release of “Appropriate Dosing for Parenteral Nutrition” recommendations (bit.ly/2UsuPmb). “It takes a lot of effort to adjust systems for PN dosing in the case of a shortage—and to change it back,” he said. “But once you have product back, you need to go back to your optimal systems to do the best for your patients.”