Parenteral nutrition trace elements

Manganese is often present in mineral supplements, in hemopoietic formulations, and in some solutions for parenteral nutrition. Trace elements are required in patients receiving long-term parenteral nutrition (1), and the use of manganese has been reviewed (2). 

O Parenteral nutrition (PN), also called total parenteral nutrition (TPN), is the intravenous administration of fluids, macronutrients, electrolytes, vitamins, and trace elements for the purpose of weight maintenance or gain, to preserve or replete lean body mass and visceral proteins, and to support anabolism and nitrogen balance when the oral/enteral route is not feasible or adequate. 

PN should provide a balanced nutritional intake, including macronutrients, micronutrients, and fluid. Macronutrients, including amino acids, dextrose, and intravenous lipid emulsions, are important sources of structural and energy-yielding substrates. A balanced PN formulation includes 10% to 20% of total daily calories from amino acids, 50% to 60% of total daily calories from dextrose, and 20% to 30% of total daily calories from intravenous lipid emulsion. Micronutrients, including electrolytes, vitamins, and trace elements, are required to support essential biochemical reactions. Parenteral... 

Computer simulation has been used to predict the speciation of various trace elements during chelate therapy > and in total parenteral nutrition... 

Lipid peroxides are also able to react with other components of parenteral nutrition admixtures (trace elements), causing a drop in pH with the subsequent potential for physical-chemical instability [29]. Table 11 shows the peroxide value and the pH drop in a pure lipid emulsion and a lipid-containing AlO admixture stored in EVA bags under different conditions of temperature and light exposure in the presence and absence of trace elements. 

Steger, P. J. K., and Mtihlebach, S. F. (2000), Lipid peroxidatoin of intravenous lipid emulsions and all-in-one admixtures in total parenteral nutrition bags The influence of trace elements, J. Parenteral Enteral Nutr., 24, 37M1. 

Bohrer, D., do Nascimento, P. G, Binotto, R., and Carlesso, R. (2001), Influence of the glass packing on the contamination of pharmaceutical products by aluminium. Part II Amino acids for parenteral nutrition, J. Trace Elements Med. Biol., 15,103-108. 

Deficiency syndromes of Zn, Cu, Cr, Se and Mo have occurred in patients on total parenteral nutrition (TPN). There is still much research to be done in assessing the nutritional status of many elements and understanding their metabolism, so that normal dietary intake may be supplemented for health benefits. Table 2 is a summary of the amounts required, the functions and the nutritional (usually dietary) imbalances in humans, where known, of the essential trace elements.31-33 (Note that this summary does not attempt to include imbalances related to environmental toxicology and occupational hazards.) Several trace elements have important functions in the immune system. Some are associated with nucleic acid. Others have structural roles, such as Si in cartilage, F and Zn in bone. They may be parts of vitamins, such as Co in vitamin B12, or hormones, such as iodine in thyroid hormones, Zn and Cr have a role in the synthesis and action of insulin.31-33... 

Selenium has been recognized as an essential trace element in the diets of man and animals for many years (1) Another strong indication of its essentiality is the fact that it is an essential component of the enzyme glutathione peroxidase (2) Recently, scientists from the People s Republic of China demonstrated that Keshan disease (a cardiomyopathy in children) was correlated with low dietary selenium Intakes ( ) and could largely be prevented with supplementation Similarly, poor selenium nutrition in patients receiving total parenteral nutrition has been linked to muscular discomfort (4) and cardiomyopathy ( ) ... 

Iron is an essential element in nutrition, and its inclusion in any long-term parenteral nutrition regimen should be mandatory. However, it is not included in all trace element formulations, although this varies from country to country most European products include 20 pmol of iron in trace element formulations. While it might be considered unnecessary to include iron as a daily supplement, because of safety and pharmaceutical considerations, there is ample evidence that the use of iron-containing trace element formulations is both safe and efficacious, with no associated adverse effects. 

Figure 30-1 Consequences of inadequate mineral or trace element Intake. (From Shenfdn AfAHwood AIC.Troce e/ements and vitamins in adult intravenous nutrition. In Rombeau JL, Rolandelli RH, eds. Clinical nutrition Parenteral nutrition. Philadelphia WB Saunders Co, 2001 60-79.)...

Greene HL, Hambidge KM, Schanler R, Tsang RC. Guidelines for the use of vitamins, trace elements, calcium, magnesium, and phosphorus in infants and children receiving total parenteral nutrition report of the Subcommittee on Pediatric Parenteral Nutrient Requirements from the Committee on Clinical Practice Issues of the American Society for Chnical Nutrition. Am J Clin Nutr 1988 48 1324-42. 

Often the condition leading to the requirement for parenteral nutrition has seriously depleted the trace element stores of the patient concerned and so it is vitally important that adequate amounts of trace elements are present in parenteral nutrition fluids. 

American Medical Association. Guidelines for essential trace element preparations for parenteral use A statement by the Nutrition Advisory Group. JPEN J Parenter Enter Nutr 1979 3 263-267. 

Aqueous parenteral preparations can contain trace amounts of heavy metal ions in concentrations sufficient to catalyze oxidative reactions. Aqueous parenterals are produced with the use of Water for injection, which complies with the limit test for heavy metals (European Pharmacopoeia, 2002). This is, however, no guarantee for exclusion of metal ions. Heavy metal contamination brought into the formulation by excipients is also a problem, especially for sugars, phosphate, and citrate (Nema et al., 2002). Heavy metals may also be extracted from the container by the preparation (European Pharmacopoeia, 2002 see Section 14.3). Moreover, trace elements like zinc, copper, manganese, and chromium constitute important components in several parenteral nutrition formulas (Trissel, 2001). 

All infants, on admission to the neonatal intensive care unit, were established on parenteral fluids within the first hour of day 1 at 80 ml/kg/day with a solution of electrolytes, dextrose 10%, amino acids (Vaminolact, Fresenius Kabi, Cheshire, UK) and a phosphate supplement (Addiphos, Fresenius Kabi, Cheshire, UK). Fluid intakes were thereafter managed on the basis of clinical requirements. On day 2 of life, and thereafter, the solution was further supplemented with water-soluble vitamins (Solvito N, Fresenius Kabi, Cheshire, UK) and trace elements (Peditrace, Fresenius Kabi, Cheshire, UK), to the levels recommended by the manufacmrer. In tandem, a fat emulsion solution (Intralipid 20%, Fresenius Kabi, Cheshire, UK) with added fat-soluble vitamins (Vitfipid, Fresenius Kabi, Cheshire, UK) was infused, initially at 8ml/kg/ day, increasing maximally to 18 ml/kg/day by posma-tal day 5. Enteral feeds were started, when the condition of the infant was stable, as hourly boluses of 0.5—1 ml/h. Thereafter enteral feed volumes were gradually increased as determined by the infants clinical condition, with reciprocal reductions in the volume of parenteral nutrition infused. No infant progressed beyond hourly bolus feeds for the duration of the study. 

L. lllano, M, Delanghe, H. van den Baviere, and A. Lauwers. Effeet.s of electrolytes in the presence of some trace elements on the stability of all-in-one emulsion mixtures for total parenteral nutrition. J, Clin. Hosp. Pharm., 9 87-93, 1984. 

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