RESUMEN
Background: Total parenteral nutrition (TPN) is a life-saving therapy for patients with chronic intestinal failure. TPN typically consists of macronutrients (amino acids, dextrose, and lipids) as well as micronutrients (multi-vitamins [MVI] and trace elements) to meet fluid, calorie, and micronutrient needs. With the early years of PN administration, multiple deficiencies were noted leading to guidelines regarding need for daily use of essential trace element and MVI preparation for parenteral use. Unfortunately, during the last few years we have seen multiple shortages of PN related supplies including the most recent shortage of parenteral MVI preparation. Major organizations such as ASPEN have developed recommendations regarding management of shortages, however their clinical impact has not been fully evaluated. The current study evaluated the impact of MVI shortage on change in clinical practice and the prevalence of deficiency. Method(s): A retrospective review of electronic medical records for patients who received TPN during time of shortage in IV multivitamins supply due to COVID-19 crisis between January 2021 and June 2021. In our program, the shortage affected one TPN supplier. We included patients who received their TPN from affected supplier and who were tested for micronutrients including Vitamins A, B12, C, and D in the 6 months preceding the shortage in supply (period 1) as well as during the shortage period (period 2). Period 1 was defined as from July 1, 2020, to December 31, 2020, and period 2 was defined as from January 1, 2021, to June 30, 2021. In addition to baseline clinical characteristics, we captured changes in studied micronutrients. Result(s): Current retrospective analysis of a prospectively maintained database noted 21 patients (mean age of 63.3 +/- 13.8, 62% female) were impacted by MVI shortage during study period (Table 1). Most common primary diagnosis was Crohn's disease (33.3%) followed by enterocutaneous fistula (19%), and gastrointestinal dysmotility (14.3%). In 19/21 (90%) patients, MVI was administered 3 days per week in PN. In the remaining two patients who had short bowel,MVI was continued 7 days per week. Additionally, 19/21 (90%) patients also were supplemented orally with Vitamin D (17/21), Vitamin B12 (5/21), MVI (3/21), Vitamin C (1/21). There was a decline in average Vitamin C levels between the two study periods (Table 2) with a trend towards a decline in average 25-hydroxy vitamin D levels, while mean vitamin A and B12 levels did not change significantly. There was a significant increase in Vitamin D and C deficiencies, while no increase in deficiencies in Vitamin E, A, and B12 levels was noted (Figure 1). Conclusion(s): Unfortunately, shortages of key PN related supplies have become commonplace in the last few years. The most recent shortage affected MVI supplies. Our group managed the shortage through a combination of reduction of parenteral MVI administration to 3 days per week along with additional supplementation of specific micronutrients orally. Although with this strategy, there was an increase in Vitamin D and C levels falling below reference range, no significant deficiencies were noted. (Table Presented).
RESUMEN
Background : SARS-CoV-2 virus infection (COVID-19) is associated with high rates of venous thromboembolism (VTE). Immune mediated thrombosis has been implicated as a driving factor. Aims : To characterize coagulopathy by assessing thrombin generation kinetics and Von Willebrand Factor (VWF) and to characterize thromboinflammation through neutrophil extracellular trap (NET) formation in COVID-19 patients (pts). Methods : We collected plasma samples from 67 COVID-19 pts in the Emergency Department (ED) and 38 healthy volunteers (HV). Plasma thrombin generation kinetics were assessed using Calibrated Automated Thrombogram (CAT) and expressed as lag time (LT), peak height (PH), time to peak (ttPeak), and endogenous thrombin potential (ETP-total thrombin generated). NET formation was quantified through citrullinated nucleosome ELISA (H3NUC). VWF antigen/activity levels were determined by latex immunoassay. Factor VIII levels were performed using one-stage optical clot detection. VTE events were tracked through electronic medical records. This study was approved by the Institutional Review Board and patients were consented. Mann-Whitney test was performed, P < 0.05 considered significant. Results : Subject characteristics are described in Table 1. Of the 67 pts, 50.7% required admission and 31.3% supplemental oxygen. COVID-19 pts had longer LT and ttPeak, greater H3NUC, VWF antigen and activity level, and Factor VIII levels as compared to HV (Table 2). Admitted pts had longer LT (4.33 min [3.67, 5.67];3.33 min [3.00, 4.00], P < 0.001), ttPeak (7.73 min [6.84, 8.50];7.15 min [6.05, 7.75], P = 0.011), greater VWF antigen (247 IU/dL [208, 298];168 IU/ dL [103, 222], P < 0.001), activity (196 IU/dL [164, 238];130 IU/dL [94, 172], P < 0.001), and Factor VIII (159 IU/dL [129, 194];119 IU/dL [88, 169], P = 0.023) as compared to those not admitted. Conclusions : Symptomatic COVID-19 pts have prolonged initiation of thrombin generation, especially those requiring admission. Greater VWF activity and NETosis suggest systemic thromboinflammation in COVID-19 associated coagulopathy.