Trace Elements in Parenteral Nutrition: Considerations for the Prescribing Clinician

Abstract

Trace elements (TEs) are an essential component of parenteral nutrition (PN). Over the last few decades, there has been increased experience with PN, and with this knowledge more information about the management of trace elements has become available. There is increasing awareness of the effects of deficiencies and toxicities of certain trace elements. Despite this heightened awareness, much is still unknown in terms of trace element monitoring, the accuracy of different assays, and current TE contamination of solutions. The supplementation of TEs is a complex and important part of the PN prescription. Understanding the role of different disease states and the need for reduced or increased doses is essential. Given the heterogeneity of the PN patients, supplementation should be individualized.

No Gut No Gain! Enteral Bile Acid Treatment Preserves Gut Growth but Not Parenteral Nutrition–Associated Liver Injury in a Novel Extensive Short Bowel Animal Model

“…One of the most significant of these side effects is progressive liver disease and gut atrophy. 47,55 Although there has been some interest in the role of ω 3-derived fats, [56][57][58] as well as infection prevention 59 and strict micronutrient management protocols 60,61 for patients receiving PN, to date there are no definitive ameliorative or curative strategies. In addition, mechanisms leading to PNassociated complications remain largely unknown, 62 which further complicates therapeutic interventions.…”

Parenteral Provision of Micronutrients to Adult Patients: An Expert Consensus Paper

“…Zinc requirements are increased in intestinal and biliary losses, including fistulae, severe diarrhea, and chyle leaks, as well as sepsis, hypercatabolic states, and burns, where additional supplementation is required . Replacement of about 12 mg of Zn (IV) per liter of GIT losses in patients with fistulae, stomas, and diarrhea has been recommended .…”

“…54 Zinc requirements are increased in intestinal and biliary losses, including fistulae, severe diarrhea, and chyle leaks, as well as sepsis, hypercatabolic states, and burns, where additional supplementation is required. 55 Replacement of about 12 mg of Zn (IV) per liter of GIT losses in patients with fistulae, stomas, and diarrhea has been recommended. 22 Additional Zn, over and above the daily recommended parenteral doses, may be added to short-term IV infusions in at-risk patients; however, it must also be noted that there is inadequate published information on the compatibility between injectable Zn solutions and other IV admixtures.…”

Monitoring of long‐term parenteral nutrition in children with intestinal failure

“…Given that tissues biopsies are too invasive, more reliable markers need to be established for an accurate assessment of micronutrient status. Another important consideration is that most micronutrients are acute‐phase reactants resulting in variability in serum levels during active inflammation with falsely low or high levels (Table ). Therefore, assessment of serum micronutrients should be avoided during periods of stress and be accompanied by measurement of the C‐reactive protein level to assist in the interpretation of results.…”

“…Serum magnesium is monitored every 1–3 months and supplemented accordingly. Zinc is mainly excreted in feces, and patients with high gastrointestinal losses may require additional supplementation in PN . Serum zinc level is routinely monitored every 6 months or more frequently in case of high gastrointestinal or cutaneous losses.…”