A.S.P.E.N. Position Paper

Abstract

The parenteral multivitamin preparations that are commercially available in the United States (U.S.) meet the requirements for most patients who receive parenteral nutrition (PN). However, a separate parenteral vitamin D preparation (cholecalciferol or ergocalciferol) should be made available for treatment of patients with vitamin D deficiency unresponsive to oral vitamin D supplementation. Carnitine is commercially available and should be routinely added to neonatal PN formulations. Choline should also be routinely added to adult and pediatric PN formulations; however, a commercially available parenteral product needs to be developed. The parenteral multi–trace element (TE) preparations that are commercially available in the U.S. require significant modifications. Single‐entity trace element products can be used to meet individual patient needs when the multiple‐element products are inappropriate (see Summary/A.S.P.E.N. Recommendations section for details of these proposed modifications).

Trace Elements in Parenteral Nutrition: Considerations for the Prescribing Clinician

“…Acute copper toxicity results in vomiting, diarrhea, acute kidney injury, hepatic necrosis, and death [3]. Wilson’s disease, a genetic abnormality of cellular transport, is an example of chronic copper toxicity.…”

“…Wilson’s disease, a genetic abnormality of cellular transport, is an example of chronic copper toxicity. Symptoms of chronic toxicity include neurological disorders, renal insufficiency, and cirrhosis [3]. Blaszyk et al performed biopsies on 28 patients on long-term PN with intestinal failure-associated liver disease as well as 10 controls with drug-induced cholestatic liver disease and showed that 89% of PN patients versus all controls had mildly elevated hepatic tissue copper, but 29% of the PN patients had levels above 250 mcg/g, the diagnostic threshold for Wilson’s disease [15].…”

“…The amount of hepatic copper did not correlate with the duration of PN or serum copper levels, but patients with significant cholestasis accumulated more copper than patients with no or minimal cholestasis. Copper accumulation can contribute to and cause liver damage [3]. …”

“…As patients were maintained on home parenteral nutrition (HPN) for longer durations of time, additional light was shed on TEs. In the following decades, as more information came from toxicity and balance studies, as well as reports in the literature of PN contamination, further adjustments to recommended doses were made [3]. In critical illness, the processes of inflammation, infection, and oxidative stress increase the metabolic requirements for certain trace elements.…”

Componentes de las mezclas de nutrición parenteral para pediatría

“…La mayoría de estas recomendaciones fueron apoyadas por la European Society for Clinical Nutrition and Metabolism (ESPEN) (30) Ambos tienen como vehículo Intralipid 10% y tiene que aña-dirse a los lípidos o las emulsiones de NP con lípidos por lo que los niños que no requieran lípidos no pueden recibir vitaminas liposolubles con este preparado.…”