Avoiding Patient Harm With Parenteral Nutrition During Electrolyte Shortages

Abstract

We report a case of a patient with gastrointestinal dysmotility and substantial drainage losses who required parenteral nutrition (PN) and developed a non-anion gap metabolic acidosis secondary to a shortage of concurrent potassium acetate and sodium acetate PN additives. We describe how severe PN-associated metabolic consequences were averted during this acetate shortage. Summary: The patient with inability to swallow and significant weight loss was admitted to the hospital and given PN after failure to tolerate either gastric or jejunal feeding due to dysmotility and severe abdominal distension and discomfort. PN was initiated and the nasogastric and jejunal tubes were left to low intermittent suction or gravity drainage (average losses of 800 mL and 1600 mL daily, respectively) to reduce abdominal distension. The patient had been stable on PN for approximately 2 months prior to when a shortage in potassium acetate and sodium acetate occurred. As a result, potassium and sodium requirements had to be met with chloride and phosphate salts. The patient developed a non-anion gap metabolic acidosis after 11 days of acetate-free PN. Progression to severe acidemia was avoided by administration of sodium bicarbonate daily for 3 days and replacement of 0.9% sodium chloride supplemental intravenous fluid with lactated ringers solution. Conclusion: This case report illustrates that PN component shortages require clinicians to closely monitor patients who require PN. In addition, clinicians may need to use creative therapeutic strategies to avoid potential serious patient harm during PN component shortages.

Premixed vs Compounded Parenteral Nutrition: Effects of Total Parenteral Nutrition Shortage on Clinical Practice

“…At another institution, they published a case report of laboratory abnormalities indicating significant acidosis due to a shortage of acetate-containing electrolytes. Substitution with their chloride salts led to significant acidosis requiring intervention, but patient harm was avoided [23].…”

“…Part of this drive was the thought that pTPN may be more cost-effective and lead to fewer bloodstream infections. These potential benefits must be weighed against the need for individual adjustment to meet specific patient needs for electrolytes, vitamins, and minerals [21][22][23][24][25]. While there is limited data regarding the change in use of compounded vs pTPN, particularly in times of shortage [24,26], we will review the literature regarding three issues: cost, ability to meet nutritional needs, and risk of bloodstream infections or other complications as consideration is given to future practice, both during shortage, but potentially to meet each unique institutional and patient needs.…”