Parenteral supplementation

L B. Supplement with vitamin A. Vitamin A deficiency symptoms include night blindness that can lead to corneal ulceration. This deficiency can occur in patients with impaired liver storage or fat malabsorption. Dairy products, such as milk, are a good source of vitamin A. (3-Carotene, a vitamin A precursor, is found in pigmented vegetables, such as carrots. When a deficiency is diagnosed, it is appropriate to treat the patient with a supplement rather than to rely on increased consumption of vitamin A-rich foods. A patient with pancreatic disease and malabsorption syndrome will need parenteral supplementation. 

A structured, lipid-containing dairy fat is covered by a U.S. patent (95). The invention relates to a frawi-esterification product of a mixture of fatty acids and triglycerides, including milkfat, in the form of cream or butter as the main component. The product has nutritional applications and may also be used as an enteral or parenteral supplement. 

When oral intake is precluded, the recommended daily parenteral supplementation of manganese is 0.15-0.8 mg. Manganese is mainly excreted in the bile during cholestasis serum manganese levels may rise, and manganese toxicity can result. Hjq)ermanganesemia after parenteral nutrition when first reported was linked to portosystemic encephalopathy. Patients with liver disease were particularly at risk. 

USE Nutrient sweetener, in culture media in prepd bee food. Parenteral supplement of sugar for diabetics. Fermentable intermediate in brewing. Stabilizer for polysulfides. In pharmaceutical dispensing. 

Alternatively, if huge numbers of livestock are kept on a large area of pasture, parenteral supplementation may be preferable. For example, iodine supplementation provided by an intramuscular injection of a slow release preparation, such as iodized oil, can be sufficient for several months (Chambon and Chastin, 1993). Parenteral administration of iodine is beyond the scope of this chapter and only dietary supplementation of iodine is discussed here. 

Koenig, J. S., Bulant, E., Dmml, W., Fischer, M., Balcke, R, and Elmadfa, I., 1993, Antioxidant status of patients on hemodialysis before and after parenteral supplementation with sodium selenite, Clin. Nutr. 12(S2) 27-28. 

Biomedical Uses. The molybdate ion is added to total parenteral nutrition protocols and appears to alleviate toxicity of some of the amino acid components in these preparations (see Mineral NUTRIENTS) (97). Molybdenum supplements have been shown to reduce iiitrosarnine-induced mammary carcinomas in rats (50). A number of studies have shown that certain heteropolymolybdates (98) and organometaUic molybdenum compounds (99) have antiviral, including anti-AIDS, and antitumor activity (see Antiviral agents Chemotherapeutics, anticancer). 

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. 

Assess nutritional needs and recommend appropriate supplementation. When the patient is tolerating an oral diet, determine if any parenteral medications can be switched to the oral route. 

Trace elements are essential cofactors for numerous biochemical processes. Trace elements that are added routinely to PN include zinc, selenium, copper, manganese, and chromium. There are various commercial parenteral trace element formulations that can be added to PN admixtures (e.g., MTE-5 ). Zinc is important for wound healing, and patients with high-output fistulas, diarrhea, burns, and large open wounds may require additional zinc supplementation. Patients may lose as much as 12 to 17 mg zinc per liter of gastrointestinal (GI) output (e.g., from diarrhea or enterocutaneous fistula losses) however, others have demonstrated that 12 mg/day may be adequate to maintain these patients in positive zinc balance.18 Patients with chronic diarrhea, malabsorption, and short-gut syndrome may have increased selenium losses and may require additional selenium supplementation. Patients with severe cholestasis should have copper and manganese... 

Iron-deficiency anemia in chronic PN patients may be due to underlying clinical conditions and the lack of iron supplementation in PN. Parenteral iron therapy becomes necessary in iron-deficient patients who cannot absorb or tolerate oral iron. Parenteral iron should be used with caution owing to infusion-related adverse effects. A test dose of 25 mg of iron dextran should be administered first, and the patient should be monitored for adverse effects for at least 60 minutes. Intravenous iron dextran then may be added to lipid-free PN at a daily dose of 100 mg until the total iron dose is given. Iron dextran is not compatible with intravenous lipid emulsions at therapeutic doses and can cause oiling out of the emulsion. Other parenteral iron formulations (e.g., iron sucrose and ferric gluconate) have not been evaluated for compounding in PN and should not be added to PN formulations. 

Vitamins Provide standard parenteral multivitamin (containing water- and fat-soluble vitamins) in PN daily assess for any possible deficiencies, otherwise no indication for additional supplemental vitamins... 

Trace elements Provide standard parenteral trace element preparation (containing zinc, copper, manganese, chromium, and selenium) daily in PN Assess patient for any possible adjustments needed (e.g., delete copper and manganese from PN if the patient has evidence of severe cholestasis, supplemental zinc and selenium for any Gl or fistula losses) or potential deficiencies... 

As has been pointed out earlier in this chapter, the dietary consumption and historical medicinal use of carotenoids has been well documented. In the modern age, in addition to crocin, 3.7, and norbixin, 3.8, several carotenoids have become extremely important commercially. These include, in particular, astaxanthin, 3.6 (fish, swine, and poultry feed, and recently human nutritional supplements) lutein, 3.4, and zeaxanthin, 3.3 (animal feed and poultry egg production, human nutritional supplements) and lycopene, 3.2 (human nutritional supplements). The inherent lipophilicity of these compounds has limited their potential applications as hydrophilic additives without significant formulation efforts in the diet, the lipid content of the meal increases the absorption of these nutrients, however, parenteral administration to potentially effective therapeutic levels requires separate formulation that is sometimes ineffective or toxic (Lockwood et al. 2003). 

Diet clear liquids as tolerated, supplemented with parenteral fluids... 

Deficiencies were usually prevented or reversed by supplements with sodium selenate or selenite at 100 pg Se/kg ration, or 20 pg Se/kg body weight administered parenterally. 

The nutritional needs of the majority of patients can be adequately addressed with enteral supplementation. Patients who have severe disease may require a course of parenteral nutrition. 

Oral vitamin B12 supplementation appears to be as effective as parenteral, even in patients with pernicious anemia, because the alternate vitamin B12 absorption pathway is independent of intrinsic factor. Oral cobalamin is initiated at 1 to 2 mg daily for 1 to 2 weeks, followed by 1 mg daily. 

Iron supplementation is necessary to replete iron stores (Fig. 76-5). Parenteral iron therapy improves response to erythropoietic therapy and reduces the dose required to achieve and maintain target indices. In contrast, oral therapy is often inadequate. 

Hypophosphatemia is associated with chronic alcoholism, parenteral nutrition with inadequate phosphate supplementation, chronic ingestion of antacids, diabetic ketoacidosis, and prolonged hyperventilation. 

The average adult body contains approximately 4 g of iron, of which roughly two-thirds exists in the form of hemoglobin. Treatment of certain types of anemias usually consists of dietary supplementation or the administration of therapeutic iron preparations by oral and parenteral routes. Iron is often administered by i.m. as iron-dextran complex which is ferric hydroxide and dextran containing 50 mg of iron per milliliter. 

Source Parenteral Drug Association. Technical report No. 29, Points to consider for cleaning validation, PDA Journal of Pharmaceutical Science and Technology 52 Nov-Dec Supplement (1998). 

Total parenteral nutrition Total parenteral nutrition patients may develop hypomagnesemia (less than 1.5 mEq/L) without supplementation. Magnesium is added to correct or prevent hypomagnesemia. 

Parenteral For preoperative or preanesthetic medication supplement to surgical anesthesia. 

The symptoms of iron deficiency anemia include fatigue, weakness, shortness of breath, and soreness of the tongue. Therapeutic iron supplementation is used to treat this type of anemia. Oral administration of ferrous salts (generic ferrous sulfate, Feosol, Slo Fe) is preferred, but parenteral iron (iron dextran, InfeD) can be given if oral therapy fails. Toxic reactions occur more frequently after parenteral iron administration. Gastrointestinal disturbances are common following oral dosages. 

Drug interactions No formal drug interaction studies have been carried out. Clinical trials have indicated that Pulmozyme can be effectively and safely used in conjunction with standard cystic hbrosis therapies including oral, inhaled, and/or parenteral antibiotics, bronchodila-tors, enzyme supplements, vitamins, oral or inhaled corticosteroids, and analgesics. 

Parenteral administration of folic acid is rarely necessary, since oral folic acid is well absorbed even in patients with malabsorption syndromes. A dose of 1 mg folic acid orally daily is sufficient to reverse megaloblastic anemia, restore normal serum folate levels, and replenish body stores of folates in almost all patients. Therapy should be continued until the underlying cause of the deficiency is removed or corrected. Therapy may be required indefinitely for patients with malabsorption or dietary inadequacy. Folic acid supplementation to prevent folic acid deficiency should be considered in high-risk patients, including pregnant women, patients with alcohol dependence, hemolytic anemia, liver disease, or certain skin diseases, and patients on renal dialysis. 

---