First and foremost, I'll say I have no commercial relationships to disclose. As we all know, our bodies need adult multivitamins every day, and it holds true even with parenteral nutrition support, and usually in parenteral nutrition, they're given as a commercial brand multivitamin, 10 mL, additive to PN orders. But these are all the required adult parenteral MVIs. You can also get them in single-entity dosing, with the exception of biotin, panathenic acid, riboflavin, vitamins A, D, and E. Parenteral trace elements are as important as well. How we practice, which may be different than other organizations, we don't necessarily for all of our patients put all of the trace elements in the TPN. We make decisions, especially for the patients we're managing at home, decisions on whether they need all five or just two, et cetera. In critical illness, we deal with a lot of liver transplants, and sometimes we'll exclude copper and manganese in the early beginnings of TPN. But at the end of the day, it doesn't matter if it's a multivitamin or a multitrace element. We can collect lab samples, but they can be difficult to collect. They require fasting often, and measurements of serum or plasma levels don't necessarily show us that we have adequate body stores or micronutrient adequacy. So I think it's best overall as providers that we know what to look for when we are assessing our patients looking for these micronutrient deficiencies. Micronutrient deficiencies are supporting evidence for malnutrition diagnosis. The Aspen and the American Academy of Nutrition and Dietetics utilizes six characteristics currently with evidence or research being done on whether or not to include micronutrient deficiencies. They also may correlate with lab measurements and or a medical or diet history. We also know from Aspen micronutrient guidelines that they're all essential for human metabolism. We know that they are important for the utilization of macronutrients as well as every enzyme activity in the body, and therefore they should be delivered in recommended daily amounts. When we're looking at areas to assess, it should be a part of a head-to-toe examination with skin looking at petechiae, dermatitis, pellagrus, dermatosis, paleo, cirrhosis and wounds, hair looking for alopecia, light in color, corkscrew hair on the arms, with nails looking for spoon-shaped or bows or transverse lines, poor blanching, flaky nails, clubbing or splinter hemorrhages. For the eyes, we want to look for Beto spot, caramelacea, pale conjunctivitis, with the nose, nosolabia, seborrhea, and then looking at the mouth, oral cavity, teeth and lips for chelosis, angular stomatitis, spongy bloody gums, mouth lesions, dental caries, and glossitis as well as pale gum color. And for the neck, assessing for enlarged parotid or enlarged thyroid. So just to give you a few examples of what you're looking at, here in these pictures you can see what cirrhosis looks like, dry, scaly, flaky skin, which could be a deficiency in vitamin A or an essential fatty acid deficiency or from dehydration. There of course are non-nutrient causes as well, such as environmental and or hygiene factors or aging. Follicular hyperkeratosis is what you're seeing here in the pictures. Basically there's an excessive development of keratin that's in the hair follicles. It results in these rough cone-shaped elevated papules, resulting from closure of hair follicles with a white plug of sebum. This is where you'll have a deficiency in vitamin A or C or essential fatty acid deficiency. In general, malnutrition is the strongest association. And then with petechiae, as you can see there, there are small hemorrhagic spots on the skin. Could be a deficiency in vitamin C or K. Of course there's non-nutrient causes as well, such as hematologic disorders, liver disease, and anticoagulant overdose. And then like when you're looking at the scalp and hair, you want to see that the hair is shiny smooth and not easily plucked. You want to assess for color, texture, distribution, alopecia. This could be a potential nutrition deficiency in protein, zinc, essential fatty acids, or even a biotin deficiency. Of course there's non-nutrient causes for alopecia, such as male pattern baldness, cancer treatment, Cushing disease, medications, hypothyroidism, infections. Lightened hair color could be a copper, selenium, or a protein deficiency. Of course chemical alterations could be a non-nutrient cause. And then corkscrew hair on the arm could be copper or follicular hyperkeratosis from scurvy in the elderly, as well as non-nutrient causes of being chemical alteration. I put this picture of sites of absorption up that I took from our nutritional management of intestinal rehabilitation and transplantation booklet. And basically we should just look at our patients and know what their absorptive capacity is because that can depend upon what's remaining in the intestine and the colon. The quality of the intestinal lumen and the colon also will affect absorption ability. There are factors that do inhibit absorption, such as increased bile acid wasting. Fat soluble vitamins require bile acid salts for absorption. Consumption of insoluble fiber increases small intestinal transit time. Primary luminal disease, pancreatic insufficiency, poor blood flow to the gut, protein losing enteropathy, and rapid transit. We also have factors that enhance micronutrient absorption. So of course, when we have increased metabolic requirements, such as in growing, pregnancy, lactation, exercise, as well as increased small bowel mucosal mass, intrinsic factor in corticosteroids, increased vitamin 12 absorption, cellulose and pectin increased intestinal villus height and thickness, and dietary fat increases our ability to absorb fat soluble vitamins. Micronutrients also have a response to inflammation. When we have C-reactive protein and it's elevated in a response to an inflammatory state, those are times we do not want to make corrections to vitamin and trace element deficiencies. It's not recommended and it actually may increase morbidity and mortality. What you'll see in an inflammatory state is decrease in micronutrients of vitamin A, vitamin C, vitamin D and E, as well as B6, zinc, selenium, iron, and transferrin. There is no change in the B vitamins of B1, 2, and 3, and B12 and folate as well. And then copper and ferritin actually increase in inflammation. The biggest point to make in all this in dealing with micronutrient deficiencies is we all know we've been dealing with supply chain issues, not just with medicines, but also the products needed for PN for compounding. So we're often left to look for alternative therapies. We may be less familiar with those therapies. We may be less evidence-based or clinically inferior. In a paper I reviewed in April of 2019, the Mayo Clinic actually shared their experience of a rapid coordinated shift to using multi-chamber bagged PN products after Hurricane Irma and Maria when they had compromised PN product shortages, specifically amino acids. What you're seeing on the screen is the framework they used where they created a decision tree if multi-chamber PN should be used and appropriate for their patients. And if they felt that it wasn't, they put a consult in to their nutrition support services. They then determined if compound PN was appropriate. If they didn't feel compounding PN was appropriate, then they advised on an alternative plan. Amy Mayo then goes on to say in this paper that the rapid operationalization of a new product and significant practice change is possible as long as you have early engagement with stakeholders and immediate comprehensive operational and therapeutic assessment. Communication was important not only prior to, but during the implementation. As you can see on the end, they had a feedback loop to act on any areas for improvement. Aspen has also created a multi-chamber bag video series for clinicians to get familiar with multi-chamber bagged PN. For some hospitals with small amounts of TPN, multi-chamber bags may be an appropriate and cost-effective option instead of doing compounding PN for a small number of patients. All clinicians should know and be aware of other options for PN for their patients. Just a few other considerations to consider for shortages is to think about those with increased needs who have limited absorptive capacity with IV shortages. You want to have plans in place for oral supplementation and to be aware of interactions between supplementation. As an example, not to give copper and zinc when a patient is taking iron to avoid chelation. Working with your inpatient pharmacy team is important so you understand the projected length of these shortages, the reserves you have on stock, and ration that allocation to prioritize those who are higher in need for those products. With multivitamins, you may want to give those three times per week to all your patients except for those that have absorptive problems or your pediatric patients. You also want to have a conversation with your outpatient pharmacies with patients being discharged on PN either to a facility or to a skilled facility or to home so that you're aware of any shortages outside in those community pharmacies. And then one last consideration is to increase your frequency of lab work during shortages to assure that PO supplementation is adequate. So if your standard workflow is every six months get some of these lab values on micronutrients, you might want to change it to three months during the shortages. And then lastly, Aspen does continue to work with a variety of, with the FDA, pharmaceutical manufacturers, other healthcare organizations to act on these shortages and to collaborate to resolve these shortages. On these two slides I've pulled off from Aspen's website what they recommend for, what they recommend doing when there's electrolyte and mineral product shortages. Assess your patients as to the indication for PN, do they really need parenteral nutrition, or can they get nutrition from the oral or enteral route? Consider switching to oral or enterally administered mineral supplement products when oral, enteral intake is initiated, of course, except for your patients that have malabsorptive disorders. Reserve intravenous minerals for those patients receiving PN or those with a therapeutic medical need for the intervention. Limit the use of mineral additives and IV fluids to patients with disease states and clinical conditions for which they are appropriate. And then use commercially available IV mineral products as much as possible for replacement therapy. When there's prolonged shortages, mineral products that the FDA may approve for temporary importation with these products, it's very important that providers read the DEAR Healthcare Professional Letter accompanying these products so they understand them. They want to observe for increase in deficiencies with ongoing shortages. Increase your awareness and assessment for signs and symptoms of mineral deficiencies. If you're compounding for a few PNs in your hospital, maybe organizing with the hospitals in the area and creating a centralized pharmacy where you can decrease supplies going to all the smaller hospitals. Include PN component shortages and outages in the healthcare organization's strategies and procedures for managing medication shortages and outages. Make sure that severe drug product shortages are reported and reporting of any patient problems with these shortages. Thank you for your time.

multivitamins

micronutrient deficiencies

parenteral nutrition

trace elements

supply chain issues