Thank you. I'm excited to be here today and follow some great talks. I brought you some cases, so we're going to frame our structure around that. These are my disclosures today. So the first case is going to be an acute ICU patient where we have a limited ability to provide internal feeding. And then we're going to talk about what I'll call a chronically critically ill patient and talk about the implications for shortages in those patients. So let's start with our acute one. So this is a, I'm going to take you through one of my trauma calls. So this is a patient, it's Saturday night, we're in Ohio, and that's the car that they've been pulled out of. And no, that's not snow on the ground. That's the fire foam from putting the car fire out. So they bring this patient to our trauma center. It's a 31 year old male, high speed MVC. Airbags went off, seatbelt went off, or was there, and there was a seatbelt sign. They're in hemorrhagic shock, they're tachycardic, they're hypotensive. They got a CT scan, the spleen is bleeding, they go to the OR. You see this open book, pelvic fracture, the pelvis is separated wide open. So it's going to be a bad one, it's going to be a patient who bleeds a lot. So those are the blood products that we gave the patient on the floor at the end of the case, all those empty bags. So clearly a massive transfusion. Then we get to starting kind of the secondary stabilization. You've got a brain injury, an ICP monitor is put in, bilateral open femur fractures have been treated with external fixators, those bars and screws and rods. So very sick patient. Still the morning after, hypotensive, receiving some blood products on and off, doesn't end up needing Levophed but came close, hypothermic, anemic, acidotic. So how did the next few days go? Well, as you can tell, there's a lot to fix. So pretty much every day the patient's going to need another trip to the operating room. I know it's small here, but this is the flow sheet. 11 liters of blood product go in that first night. Then it trickles down after that. We have the NG tube inputs charted, which is our rough surrogate for how the tube feeding was going. Clearly on the third day of tube feeds there's a typo because we didn't give 5,000 milliliters of tube feeds. But leave it, see there's no perfection in clinical medicine. We always have to make some assumptions and some rounding. So they get their pelvic angio, they get the ICP monitor, then finally they get the pelvis stabilized and then they get the clean up, the arm fix, things like that. So here we are, we had a goal RD recommendation of 1,500 milliliters or 2,300 kcals per day. We actually got 1,280 in and that was probably better than we often would have in this patient. On day 10 we do indirect calorimetry and find out that at least by day 10 our calorimetry tells us we should be doing 3,200 kcals per day. We don't know where we would have been all those other days, but clearly very hyper metabolic. So uh-oh, we're 10,000 kcals below in our delivery of what was prescribed. We're 19,000 kcals behind, and I don't mean to overemphasize calories, but just to put the context here, we're 19,000 calories short of where we would be on the resting energy expenditure. And uh-oh, now our patient has an ileus, they have a fistula from their pancreas, and so we order perineural nutrition. We choose a three-in-one formula with a four-oil emulsion, but there's three opportunities here really to highlight. One is, you know, could we have done better? Some of those orthopedic operations, we didn't need to hold the two feeds. We could have kept them running up to and through the operating room, but we fall into those bad habits of the NPO at midnight. What else could we do? We actually have a protocol for volume-based feeding. We try to empower nursing to be able to titrate up the two feeds and play catch-up. We don't do a good job of it. I'll be honest and transparent with you about that, but we do have that protocol. And would there have been an opportunity for earlier supplemental perineural nutrition? I think so, and it's beyond the scope of today, but there is evidence to support that as well. Clearly, we know that our patient's mortality is best when we get to about 80% of their goal calories, so we're falling behind. The other thing that we're losing is we're losing muscle. Every day in the ICU, we're losing muscle. So by day seven, we've lost about 15% to 20% of our muscle mass, no matter how you measure it. By day 14, 25% to 30% of our muscle mass is lost. So what are our challenges? Well, first of all, we very rarely offer supplemental perineural nutrition. One of the challenges is that the NST team, that is how we really start PN, and they're not consulted. So they didn't know about it, so they don't have that opportunity. The other angle, especially with these intubated trauma patients, we often have, and this was a young person, presumably they're adequately nourished, but we have a lot of elderly patients as well. And you know, when they're intubated, when they have a TBI, we often are missing those pre-admission weights, we're missing the nutrition history. We often don't do a good job of circling back to family to ask those questions about how have you been eating recently? What have you had recent weight loss? And as a tertiary center, many of these patients were not in our primary care population, and so we don't have that kind of longitudinal data. It's getting better as our computer connections are improving and more systems are using the same EMR system that we do. But I think we're still starving too many patients. And then the other barrier is that we have a really high census on our NST team. If I start ordering the supplemental perinatal nutritions, they are going to freak out because they're already overworked and underappreciated. So definitely a barrier. But this is data from emergency general surgery patients in a SICU showing, and I think this is a good kind of follow-up to the previous presentation, we can kind of cherry pick those patients that are at highest risk. In this case, they used Nutrix scores. To identify patients who are going to have a significant survival advantage with the early use of supplemental perinatal nutrition. But how are the shortages impacting me? Well, in reality, I kind of live in an idealistic world. I kind of make it somebody else's problem. When I was asked to talk about this, I thought, I'm not an expert on drug shortages. But as I sit back and I think about it, well, we have really been, I think to the point made already, we've basically been practicing in this environment for my whole career. And so I think I do know a thing or two about it, which kind of surprised me, because like I said, I've never thought of this. But Hurricane Maria in particular, 2018, we had a huge impact, at least to our hospital, on the amino acid supply shortage. We actually looked at this. We divided our patients into two periods. We looked at a moderate shortage, which was kind of the first and the last month of our problems, and then the severe shortage. We actually looked at the patient's calorie and protein delivery and reviewed their charts, compared what we were doing versus the goals, and analyzed this, and actually presented it here in this building four years ago. Kind of hard to believe. So here's what we found, 289 patients during that period of time. About two-thirds of them were in the severe shortage period. We had patients, so first of all, we gave less PN, 10.9 versus 11.7 days. We gave less protein. So during the severe shortage, 19.7 grams of protein per day short of our goal, during the less severe period, 4.8. And our calorie delivery, so in the mild shortage, we were spot on. We gave patients two calories more per day than we had recommended. During our bad shortage, we were 219 calories short. So definitely dealing with some numbers here, and I'll show you some clinical outcomes data in a moment. Now, a little more recently, we had a lipid shortage. This was at my new organization. We're using CAPS Pharmacy. You see, we're kind of central and southeastern Ohio. Our pharmacy, though, comes from Cleveland. So every night, the stuff gets made in Cleveland, brought down through the state, and, you know, we had some tough choices. We had to either change our lipid away from our preferred bags, and I apologize. I use the word pre-mix all the time, and I'm interested to learn more, so slap me later. I think I forgot to say the answer, but yeah, you got to stop. Yep. I will stop. I will correct. I'm being corrected. So apologies for that, and we also reduced our lipid doses, but I felt like this is really impacting our ICU patients. So let's take a little bit of a journey because the other problem is we're still in evolution in terms of what do we even believe about what the ICU patients actually need? Well, a lot of us, I mean, not me, but in the world, a lot of us are still kind of back in the 2016 Aspen SCCM guidelines, which were actually holding lipids in the first week of practice, and even then, it was actually the most controversial guideline in that document. Only 64% of the attendees or the guideline committee members agreed with that recommendation, even though it went into the document, and a lot of it had to do with the availability of the lipids at the time, and at the time, they only had 100% soy oil lipid. By 2022, Aspen didn't make it kind of a top-line recommendation, but in their updated guideline, it's kind of hidden in there that ILEs are safe and they can be included at the time of initiation, even within the first week of the ICU. So clearly, in a six-year period, a pretty significant change in what they're saying. Well, also behind the scenes, Aspen was recommending in the past that the lipid doses be less than one gram per kilo per day, and that was based on the experience with soy, but now recommending generally as long as you basically, the dose that's recommended in the lipid package insert, which is going to be greater than one gram per kilo per day, except for interlipid, and not to hold it in the first week in the ICU, and that this other concern, and it's already been addressed, that we've changed our practice to the point that we kind of aren't even sure what we believe in now, because we deal with so many shortages. So what about, you know, when amino acids were short, we actually were able to increase our calories from lipid, because we did have the new lipids, and so we were able to drive up the lipid delivery, and we showed, and this is data we also published, that it was safe and effective, and our transaminase, you know, we were scared at the time, oh, we're giving more lipid, are we going to hurt livers, whatever, no, it was fine. So we, good data, and actually less inflammation, C-reactive proteins were lower, so we definitely pivoted there. Now a major concern that I have is the use of propofol. Now I'm having trouble getting perineral, like, TPN lipids in, because I have patients on so much propofol that there's no room for therapeutic perineral lipid. So unfortunately, propofol's, like, all over the place in my ICU. I tried to find some good data on this, was disappointed. The only people who I could find published on this were actually in the South American country of Columbia. They reported that their propofol use had gone up five times since the COVID pandemic. Our ventilator liberation bundle, which is kind of indirectly related to this, is also a mess, and this group reported they were 68% compliant before COVID. After COVID happened, even on the non-COVID patients, compliance dropped to 51%, and it was 32% on the COVID-positive patients. Why? Because don't want to go in the room, don't want to risk an accidental self-extubation with a pause of sedation, you know, we just, we've lost our way, unfortunately. And so we have too many patients who are receiving basically all their lipid calories from propofol. So my concern is we're holding and are underdosing the best lipid that's depriving our patients of our therapeutic benefit. We know that fish oil-containing ILEs, and this is data published in 2022, are, and I know it's a lot on the screen, but basically at the top, we see soy or soy MCT with no reduction in length of stay, soy or olive, or soy and olive, no reduction in length of stay. But we do get a reduction in length of stay when we use a fish oil-containing ILE. And then finally, infectious complications, the same kind of data. So you know, there's something to that. Now we also, and apologies again, I've got the pre-mixed here, you know, break the habit. So we made extensive use of pre-mixed bags, University of Wisconsin did a nice job of writing this up. They did two papers looking at both electrolyte, phosphate shortages, lipid shortages, all of it. Clearly, multi-chamber bags have a significant role in your management of shortages. What else? And I'm going to steal a moment or two over, if that's okay, sorry. So electrolyte shortages. So we have patients who are in danger of refeeding phenomena, refeeding syndrome. We know, as we give carbohydrates, we see that intracellular shift of electrolytes. And so we really need to be on it, giving patients electrolytes. And I just wanted to point out that Aspen in 2020 made a really nice document about refeeding syndrome risk assessments. And since I was asked to talk about patients at risk in a shortage, these are the patients at risk in a shortage. We need to be on it with them. We had some fun with this. So we thought, well, you know, we can do all that, but we can also look at imaging. If somebody has no muscle, when you look at their initial trauma CT scan, their initial general surgery bowel perforation CT scan, they're going to be at risk. And we quantified this and actually found that those patients who had low muscle density, when they, these are all perinatal nutrition patients, low muscle density, longer ICU stays, longer time on the ventilator, and on the next slide, much more likely to develop hypophosphatemia with the initiation of TPN. So clearly these are patients who are at risk. And if we're in a shortage environment and we're being stingy, we're going to have trouble. So we also were interested in, you know, what kind of harm have we seen? This is not specifically the ICU, but many of these patients were in the ICU. Back in 2014, kind of the fallout of that earlier drug shortage we talked about, mostly amino acids, we saw a negative impact on length of stay and the overall cost of hospitalization when we were in a shortage. So got to wrap it up here. Case number two, chronic critical illness. This is a patient who had a gram patch repair. It leaked. When it leaked, it eroded the colon. Now they've had a colostomy, open abdomen. It's a mess. They're on CRRT. This is their abdominal wound where they dehist, had to have some mesh sewn in. So it's a hypermetabolic patient. Now this patient's also going to be at risk for trace mineral deficiencies, which I think the conclusion of this talk is it's hard to know when we're going to have issues here. So we just need to be careful. I think we have some long-term monitoring recommendations. We know that every three to six months, even in an outpatient, these need to be monitored. Burn patients is where we know the most. We lose trace minerals. The silver dressings are chelating copper, for example. And CRRT is a big burn or a big risk. This is one of our burn protocols. We're monitoring zinc, selenium, copper on a weekly basis and actually often empirically replacing it. There's data showing that you're going to lose these trace elements in CRRT. This is just good serum data from Switzerland. I stole the Vanderbilt protocol that's being presented at this meeting with the whole team here as authors. And you know, the burn ICU, the CV ICU, these are the patients who are going to be at risk when we can't feed them. So basically, in most ICU patients, antioxidants are no longer recommended. But those select populations, we still need to be very aware. I love the story of selenium, but I'm going to skip it in the interest of time. Basically to tell you that there's been a lot of really good data that tells us that selenium for most patients isn't needed. And then the final part is we were going to have this, but now we don't. We were going to have iron that we could put in for our own nutrition, but they stopped commercializing it. So sorry, too bad. And then I will share this because it's fine. So with the unconventional lipid situations, we have used some lovasa. That's a prescription FDA approved fish oil supplement. We've got one patient, I don't support this, but she's putting an ounce of Crisco down her J tube every day because she didn't want to deal with the lipids. And then we have done the safflower oil skin rub, which has been described to treat essential fatty acid deficiencies.

ICU nutrition

critically ill patients

caloric deficit

drug shortages

refeeding syndrome