A recent article in Today’s Dietician offers advice on drug shortages with TPN.
The following is a link (from a Kipp Ellsworth retweet) and an excerpt: http://t.co/CBKti0mNep
Lipids. Two US manufacturers produce three lipid concentrations (10%, 20%, and 30%) of IV fat emulsions. The 30% concentration can be used only in total nutrient admixtures. ICU patients receiving propofol can forgo IV fat emulsions, since propofol is in a lipid-based emulsion that provides 1.1 kcal/mL, just like the 10% IV fat emulsion.
Since essential fatty acid deficiency doesn’t develop until after two weeks of lipid-free PN, IV fat emulsions can be safely withheld for the first two weeks if lipids are in short supply.1 After two weeks of lipid-free PN, the minimum dose of IV fat emulsions, which is 100 g/week, can be provided to prevent essential fatty acid deficiency.
IV fat emulsions should be discontinued in patients tolerating EN and who don’t have malabsorption concerns.
IV Multiple Vitamins When there’s a shortage of IV multiple vitamins, dietitians should evaluate all patients for their ability to absorb enteral multiple vitamin supplements in capsule, tablet, liquid, or chewable forms. For patients who can’t absorb enteral vitamin supplements, the IV multiple vitamin dose should be decreased from 10 mL to 5 mL/day to conserve supplies. If IV multiple vitamins remain in short supply despite conservation efforts, the standard dose of 10 mL should be given three times per week.2
If supplies have been exhausted, PN must be supplemented intravenously with individual parenteral vitamins according to the following ASPEN recommendations: thiamin: 6 mg; folate: 0.6 mg; ascorbic acid: 200 mg; pyridoxine: 6 mg; and vitamin K: 0.5 to 1 mg/day or 5 to 10 mg/week.2 In addition, cyanocobalamin (vitamin B12) must be given intramuscularly at least once per month.2
Trace Elements Combination trace elements and individual trace element products offer alternatives to PN products in short supply.
Combination Multiple Trace Element Products Dietitians have a choice of two different multiple trace element combination products: MTE4 and MTE5. MTE4 products contain zinc, copper, chromium, and manganese and come in a standard 3 mL dose or a 1 mL concentrated dose. MTE5 products contain the same four trace elements with the addition of selenium in either the standard 3 mL dose or the 1 mL concentrated dose.
If there’s a shortage of the concentrated products, RDs can use the standard 3 mL dose of MTE4 and MTE5. When MTE4 products aren’t available, RDs can substitute the MTE5 products. If MTE5 products aren’t available, RDs should substitute MTE4 products and add 60 mcg of selenium individually to achieve the equivalent composition of MTE5.
…If no MTE products are available, individual trace elements should be added to PN solutions.
Individual Trace Elements Individual trace elements are used when combination trace element products are unavailable…
There’s no need to supplement manganese when there are shortages of multiple trace element products. Whole blood manganese levels frequently are elevated in long-term PN patients, and manganese contamination often occurs in other PN products. No alternative IV forms of chromium are available but, like manganese, there may be some chromium despite the fact it isn’t intentionally added because of its contamination potential in other PN products. RDs can evaluate a patient’s ability to absorb chromium as part of multivitamin and mineral supplementation through the enteral route and monitor for signs of deficiencies.
Other than the selenium content of MTE5 products, selenium is available as a single IV trace element product. When MTE5 products and individual IV selenium products aren’t available, RDs can consider using oral selenium supplementation.
Copper is available as a single PN trace element in two forms: IV copper chloride or IV cupric sulfate. If all supplies of IV copper have been exhausted, a patient should be evaluated for oral copper supplements.
Zinc is available in either IV zinc sulfate or IV zinc chloride. It’s important to note that if zinc is given enterally in high doses, RDs should monitor for a copper deficiency, as zinc and copper both compete for absorption with the same carrier protein when EN is used….
— Mandy L. Corrigan, MPH, RD, LD, CNSC, is a nutrition support dietitian with Coram Specialty Infusion Pharmacy.
Professional Resources • American Society of Health-System Pharmacists Drug Shortages Resource Center: www.ashp.org/menu/DrugShortages
• American Society for Parenteral and Enteral Nutrition Drug Shortages Update: www.nutritioncare.org/Professional_Resources/Drug_Shortages_Update
• FDA Current Drug Shortages Index: www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050792.htm
• FDA Fact Sheet: Drug Products in Shortage in the United States: www.fda.gov/RegulatoryInformation/Legislation/FederalFoodDrugandCosmeticActFDCAct/ SignificantAmendmentstotheFDCAct/FDASIA/ucm313121.htm
• FDA Frequently Asked Questions About Drug Shortages: www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050796.htm
• Fresenius Kabi Adult Multitrace Element Availability (product information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM355392.pdf
• Fresenius Kabi Pediatric Multitrace Element Availability (product information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM354265.pdf
• Fresenius Kabi Phosphate Injection Availability (product information): www.fda.gov/downloads/Drugs/DrugSafety/DrugShortages/UCM354277.pdf
• National Medication Errors Reporting Program (patients and clinicians): www.ismp.org/orderforms/reporterrortoISMP.asp
For More Information The following references can serve as viable resources for dietitians to learn more about parenteral nutrition drug shortages and their impact on patient safety and patient care:
• Buchman AL, Howard LJ, Guenter P, Nishikawa RA, Compher CW, Tappenden KA. Micronutrients in parenteral nutrition: too little or too much? The past, present, and recommendations for the future. Gastroenterology. 2009;137(5 Suppl):S1-S6.
• Corrigan ML, Kirby DF. Impact of a national shortage of sterile ethanol on a home parenteral nutrition practice: a case series. JPEN J Parenter Enteral Nutr. 2012;36(4):476-480.
• Holcombe B. Parenteral nutrition product shortages: impact on safety. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):44S-47S.
Related Blog Posts:
- Drug Shortages and Selenium Deficiency | gutsandgrowth
- Critical drug shortages in U.S. | gutsandgrowth
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) and specific medical management interventions should be confirmed by prescribing physician. Application of the information in a particular situation remains the professional responsibility of the practitioner.