Vitamins parenteral nutrition

Manufacture of vitamin C starts with the conversion of sorbitol to L-sorbose. Sorbitol and xyHtol have been used for parenteral nutrition following severe injury, bums, or surgery (246). An iron—sorbitol—citric acid complex is an intramuscular bematinic (247). Mannitol administered intravenously (248) and isosorbide administered orally (249) are osmotic diuretics. Mannitol hexanitrate and isosorbide dinitrate are antianginal dmgs (see Cardiovascular agents). 

Alimentary biotin deficiency is rare. It may, however, occur in patients on long-term parenteral nutrition lacking biotin or in persons who frequently consume raw egg white. Raw egg white contains a biotin-binding glycoprotein, called avidin, which renders biotin biologically unavailable. Pharmacological doses of the vitamin (1-10 mg/d) are then used to treat deficiency symptoms. There are no reports of toxicity for daily oral doses up to 200 mg and daily intravenous doses of up to 20 mg [2]. 

Panthenol is frequently used in ointments and solutions for the treatment of burns, anal fissures, and inflammation of the conjunctiva. The vitamin has to be substituted in patients on total parenteral nutrition and in those who regularly undergo dialysis. Hypervitamin-osis has not been observed for doses up to 5 g/d (22). Furthermore, the administration of pantothenic acid leads to improved surgical wound healing due to its antiinflammatory properties. 

No specific dietary restrictions are recommended for patients with IBD, but avoidance of high-residue foods in patients with strictures may help to prevent obstruction. Nutritional strategies in patients with long-standing IBD may include use of vitamin and mineral supplementation. Administration of vitamin B12, folic acid, fat-soluble vitamins, and iron may be needed to prevent or treat deficiencies. In severe cases, enteral or parenteral nutrition maybe needed to achieve adequate caloric intake. 

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. 

A chronically iU patient on long-term (home) parenteral nutrition develops metabolic acidosis, a grayish pallor, scaly dermatitis, and alopecia (hair loss). These symptoms subside upon addition of the B vitamin biotin to the alimentation fluid. 

Gerlach, T., Biesalski, H. K., Weiser, H., Haeussermann, B., and Baessler, K. H. (1989). Vitamin A in parenteral nutrition Uptake and distribution of retinyl esters after intravenous application. Am. ]. Clin. Nutr. 50,1029-1038. 

Peroxide formation has also been observed in multivitamin solutions for parenteral nutrition. Lavoie and co-workers [30] have studied the action of light, air, and composition on the stability of multivitamin formulations, and also total parenteral nutrition (TPN) admixtures containing and not containing vitamins and fatty acids. They analyzed the generation of peroxide in multivitamin solutions and in TPN for adults and neonates. The analysis of multivitamin solutions for enteral use revealed the presence of peroxides at the initial opening of the bottle. The levels were higher in Poly-Vi-Sol (vitamin A, Vitamin D, and vitamin C, vitamin Bb riboflavin, and... 

FIGURE 7 Influence of a lipid emulsion and daylight on peroxide levels in freshly prepared solutions of parenteral nutrition containing multivitamins (PN + MVI and PN + Lipid + MVI). (PN = parenteral nutrition MVI = multi vitamin preparation.) The data represent the mean SEM,n = 3 the variations are not depicted because of their small size relative to the symbols. The peroxide content rose significantly over time (P < 0.001), and exposure to daylight had a significant effect on peroxide generation (P < 0.001) [33]. 

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... 

The water-soluble salt of vitamin K3 (menadione) should never be used in therapeutics. It is particularly ineffective in the treatment of warfarin overdosage. Vitamin K deficiency frequently occurs in hospitalized patients in intensive care units because of poor diet, parenteral nutrition, recent surgery, multiple antibiotic therapy, and uremia. Severe hepatic failure results in diminished protein synthesis and a hemorrhagic diathesis that is unresponsive to vitamin K. 

No specific information was located regarding nutritional factors that might influence the absorption or toxicity of DEHP. Because DEHP might exert toxic effects on the testes through depletion of zinc or vitamin E, and both zinc and vitamin E deficiencies are not uncommon in preterm infants due to side effects of parenteral nutrition, depletion of these substances could increase the potential for DEHP-induced testicular toxicity (Chan et al. 1999 Obladen et al. 1998 Roth et al. 1988). DEHP could also exacerbate zinc and vitamin E deficiencies that occur in preterm infants from other causes (FDA 200lh). 

Severe negative nitrogen balance may occasionally have to be corrected by hyperalimentation or total parenteral nutrition (TPN). Intravenous solutions used in TPN contain essential and nonessential amino acids, plus a source of calories in the form of fat and carbohydrate. They "spare" the administered amino acids and allow them to be used for tissue repair. The TPN fluid must also contain all other nutritional factors required for life, including essential fatty acids, vitamins, and minerals. Severe metal and essential fatty acid deficiencies have been observed in situations in which such inclusions had not been made. 

Equally, demonstrating that a compound has a physiological function as a coenzyme or hormone does not classify that compound as a vitamin. It is necessary to demonstrate that endogenous synthesis of the compound is inadequate to meet physiological requirements in the absence of a dietary source of the compound. Table 1.3 lists compounds that have clearly defined functions, but are not considered vitamins because they are not dietary essentials endogenous synthesis normally meets requirements. However, there is some evidence that premature infants and patients maintained on long-term total parenteral nutrition may be unable to meet their requirements for carnitine (Section 14.1.2), choline (Section 14.2.2), and taurine (Section 14.5.3) unless they are provided in the diet, and these are sometimes regarded as... 

Subjects who are maintained for prolonged periods by total parenteral nutrition are obviously wholly dependent on what is provided in the nutrient mixture, normally with no contribution from intestinal bacteria. A great deal has been learned from such patients, including the essentiality of the amino acid histidine, and evidence that endogenous synthesis of taurine (Section 14.5.3) and carnitine (Section 14.1.2) may not be adequate to meet requirements without some dietary provision. However, for obvious ethical reasons, such patients have not been subjected to trials of graded intakes of vitamins, but are generally provided with amounts calculated to be adequate and in excess of minimum requirements. 

A further problem with studies in patients maintained on long-term total parenteral nutrition is that they are not normal healthy subjects - there is some good medical reason for their treatment Furthermore, they will have little or no enterohepatic recirculation of vitamins, and hence may have considerably higher requirements than normal there is considerable enterohepatic circulation of folate (Section 10.2.1) and vitamin B12 (Section 10.7.1). 

On the basis of studies in patients who developed deficiency during total parenteral nutrition, and who are therefore presumably wholly reliant on an exogenous source of the vitamin - with no significant contribution from intestinal bacterial synthesis - the provision of 60 fxg of biotin per day for adults receiving total parenteral nutrition is generally recommended (Bitsch et al., 1985). 

In addition to the established vitamins, a number of organic compounds have clear metabolic functions they can be synthesized in the body, but it is possible that under some circumstances (as in premature infants and patients maintained on long-term total parenteral nutrition) endogenous synthesis may not be adequate to meet requirements. These compounds include biopterin (Section 10.4), carnitine (Section 14.1), choline (Section 14.2), creatine (Section 14.3), inositol (Section 14.4), molybdopterin (Section 10.5), taurine (Section 14.5), and ubiquinone (Section 14.6). 

In many animals, dietary deprivation of choline leads to liver dysfunction and growth retardation, and some patients maintained on choline-free total parenteral nutrition develop liver damage that resolves when choline is provided, suggesting that endogenous synthesis may be inadequate to meet requirements (Zeisel, 2000). There is inadequate information to permit the setting of reference intakes, but the Acceptable Intake for adults is 550 mg (for men) or 425 mg (for women) per day (Institute of Medicine, 1998). In experimental animals choline deficiency is exacerbated by deficiency of methionine, folic acid, or vitamin B12, which impairs the capacity for de novo synthesis. 

Lemoyne M, Van Gossum A, Kurian R, and Jeejeebhoy KN (1988) Plasma vitamin E and selenium and breath pentane inhome parenteral nutrition patients. American Journal of Clinical Nutrition 48,1310-15. 

Smith JL, Canham JE, Wells PA. Effect of phototherapy light, sodium bisulfite, and pH on vitamin stability in total parenteral nutrition admixtures. J Parent Enter Nutr 1988 12 394-402. 

Schmutz CW, Martinelli E, Miihlebach S. Stability of vitamin Kj assessed by HPLC in total parenteral nutrition (TPN) admixtures. Clin Nutr 1992 ll(suppl) 110-lll. Billion-Rey F, Guillaumont M, Frederich A. Stability of fat-soluble vitamins A (retinol pabnitate), E (tocopherol acetate), and Kj (phylloquinone) in total parenteral nutrition at home. J Parent Enter Nutr 1993 17 56-60. 

Chen MF, Boyce W, Triplett L. Stability of the B vitamins in mixed parenteral nutrition solution. J Parent Enter Nutr 1983 7 462-464. 

Choline, supplied as dietary PC or as free choline, is required in the diet by rats. Although it has not been established that choline is required by humans, it is probably an essential nutrient and may, in the future, be classified as an essential amine or vitamin, Its possible requirement is a concern to clinicians feeding patients by total parenteral nutrition (TpN), In this type of feeding, which may be used for a year or longer, the patient is sustained intravenously with an artificial, chemically defined diet. The choline in foods occurs mainly as PC rather than as free choline. PC is a more desirable dietary component because, when free choline is consumed in large amounts, it is degraded by the gut bacteria to produce trimethylamine, an odoriferous compound (Magil et ai, 1981). 

Persons at risk for EFA deficiency tend to be the same as those at risk for vitamin E deficiency. Some signs are shared by both defidencies. Premature infants may be at risk for EFA deficiency because of their low stores of lipids and their rapid growth, especially when they are fed diets that do not contain EFAs. For example, fats have been omitted from diets used to feed preterm infants (to avoid a variety of complications). EFA deficiency may develop later in life with fat malabsorption syndromes, EFA deficiency has presented in adults fed by total parenteral nutrition for longer periods, where EFAs had not been included in the liquid diet. 

Oils such as safflower and soybean are used in total parenteral nutrition products, where they serve as a fat source and as carriers for fat-soluble vitamins. The U.S. Pharmacopeia (USP) requirement for injectable oils is as follows ... 

A young man developed marked deterioration in his vision and oscillating vision, despite normal optic fundi, during parenteral nutrition he went on to develop a characteristic Wernicke s encephalopathy, confirmed by characteristic findings on MRI brain scan (42). The serum vitamin Bi concentration was 110 pg/ml (reference range 200-500). He responded fuUy to thiamine 300 mg/day in addition to betamethasone for 4 weeks. 

Parenteral nutrition was used to support a patient requiring autologous blood stem-cell transplantation, but vitamins were excluded (the reason was not identified). After about 28 days, the patient suddenly developed severe metabolic acidosis, heart failure, and deep coma. Thiamine was immediately infused, with rapid improvement. 

These various reports stress the need to supplement parenteral nutrition with thiamine-containing vitamins unless there is adequate dietary intake, and to monitor serum thiamine and erythrocyte transketolase activity so that supplementary thiamine can be given in good time, if necessary intravenously (45). Giving thiamine will not rectify the various disorders if hepatic function is severely disturbed, because then thiamine is not phosphorylated and hence remains physiologically inactive. 

Calcium is normally considered to be safe in parenteral nutrition, and relatively high quantities are often included in neonatal and pediatric formulations. However, there is a risk of hjrpercalciuria. The pathogenesis of hjrpercal-ciuria is not readily explicable on the basis of endocrine or metabolic effects, but it has been postulated to be due to excessive calcium or vitamin D intake or aluminium overload. 

A 13-year-old boy underwent bone marrow transplantation and received parenteral nutrition without vitamins. After 15 days he had acute life-threatening lactic acidosis refractory to bicarbonate and Tris. Intravenous thiamine 100 mg produced satisfactory clinical and biochemical responses. 

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