No abstract

Background Micronutrients, an umbrella term used to collectively describe vitamins and trace elements, are essential components of nutrition. Those requiring alternative forms of nutrition support are dependent on the prescribed nutrition regimen for their micronutrient provision. The purpose of this paper is to assist clinicians to bridge the gap between the available guidelines’ recommendations and their practical application in the provision of micronutrients via the parenteral route to adult patients. Methods Based on the available evidenced‐based literature and existing guidelines, a panel of multidisciplinary healthcare professionals with significant experience in the provision of parenteral nutrition (PN) and intravenous micronutrients developed this international consensus paper. Results The paper addresses 14 clinically relevant questions regarding the importance and use of micronutrients in various clinical conditions. Practical orientation on how micronutrients should be prescribed, administered, and monitored is provided. Conclusion Micronutrients are a critical component to nutrition provision and PN provided without them pose a considerable risk to nutrition status. Obstacles to their daily provision—including voluntary omission, partial provision, and supply issues—must be overcome to allow safe and responsible nutrition practice.

CVAD complications, in particular line infection are still a major source of potentially avoidable HPN morbidity and mortality with a high cost to the healthcare system. The predominance of enteric organisms in our series raises the possibility of bacterial translocation as a significant component of the pathogenesis of line sepsis in HPN patients.

After prolonged parenteral nutrition a 12 month old infant died with pulmonary hypertension and granulomatous pulmonary arteritis. A review of necropsy findings in 41 infants who had been fed parenterally showed that two of these also had pulmonary artery granulomata, while none of 32 control patients who died from sudden infant death syndrome had similar findings. Particulate contaminants have been implicated in the pathogenesis of such lesions and these were quantified in amino acid/dextrose solutions and fat emulsions using automated particle counting and optical microscope counting respectively. Parenteral feed infusions compounded for a 3000 g infant according to standard nutritional regimens were found to include approximately 37 000 particles between 2 and 100 pm in size in one day's feed, of which 80% were derived from the fat emulsion. In-line end filtration of intravenous infusions may reduce the risk of particle associated complications. A A 1000 g female infant born at 27 weeks' gestation developed necrotising enterocolitis after a period of respiratory distress and hypoglycaemia. Perforation of the terminal ileum led to laparotomy and formation of an ileostomy, which was closed five months later. Subsequently, an anastomotic stricture and adhesions caused small bowel obstruction requiring further surgery. Septicaemia, recurrent rotavirus infection, and protracted diarrhoea precluded full enteral feeding. She died suddenly and unexpectedly at 12 months of age, having been parenterally fed for much of her life. Striking features at postmortem examination were a granulomatous pulmonary arteritis with some of the arteries being occluded by fibrin, together with dilatation and hypertrophy of the right ventricle secondary to pulmonary hypertension.Identical lesions in drug offenders are thought to be related to intravenous injection of magnesium trisilicate dust used as a lubricant in drugs intended for oral administration.' 2 Granulomata have also been described in patients who have received large volumes of intravenous fluids,3 and they can be reproduced experimentally in rabbits by injection of saline containing particulate matter. 4 The aims of this study were, therefore, to establish how often pulmonary granulomata could be found at postmortem examination in both patients who had and those who had not received parenteral nutrition, and to determine the number and size of particles in parenteral feeding solutions. Subjects and methods NECROPSY STUDY SubjectsPostmortem material from all parenterally fed infants from a regional neonatal intensive care unit who had died between 1980 and 1989 were reviewed. Forty one such patients were identified, with a median (range) gestational age of 28 weeks (25-40) and weight 880 g (450-2820). The most common indication for parenteral nutrition was prematurity and failure to tolerate enteral feeding in association with respiratory distress requiring ventilatory support (n=38); indications in the three remaining patients were necrotising enterocolitis, isch...