Trace Element Deficiencies during Total Parenteral Nutrition

The diagnostic features of copper deficiency are discussed, and a case presentation is compared with other reports in the literature. The need for copper supplement is stressed when total parenteral nutrition (TPN) is given to patients whose gastrointestinal tract is either shortened or incapable of reabsorbing copper. Since copper is recycled through the small bowel by way of the bile, any dysfunction of this area can lead to copper deficiency during TPN if inadequate amounts of copper are added to the basic TPN solutions. It is suggested that Dr. Shils' formula be used twice weekly for prophylaxis during long-term hyperalimentation and daily as a therapeutic agent when a deficiency is diagnosed.

Clinical studies on zinc metabolism during total parenteral nutrition as related to zinc deficiency

In 99 adult patients receiving controlled total parenteral nutrition (TPN), a study was made on the time course of concentrations of zinc in plasma, erythrocyte and urine in relation to the development of zinc deficiency. Zinc deficiency developed in 11 cases receiving TPN solutions not containing zinc. The plasma zinc level was significantly lower at the time of onset of zinc deficiency than in normal subjects, before the procedure of TPN, or at the time of symptomatic relief achieved by administration of zinc. The erythrocyte zinc level was slightly but not significantly lower at time of onset of zinc deficiency than in normal subjects, before TPN or at time of symptomatic relief. The urinary zinc level at time of onset of zinc deficiency was significantly lower than that in normal subjects or at the time of symptomatic relief but not significantly lower than that before TPN. A comparison between patients developing and those not developing zinc deficiency within 4 wk of the outset of TPN showed that only the plasma zinc level was significantly lower in the former than the latter group. The urinary zinc level also tended to be lower, although not significantly, in the former than the latter group but varied widely. No difference was present between the groups as to the erythrocyte zinc level. Zinc deficiency developed in none of those patients who had a plasma zinc level of 50 micrograms/dl or more but in five of 10 (50%) patients with less than 50 micrograms/dl and in all three with less than 30 micrograms/dl of zinc in plasma.(ABSTRACT TRUNCATED AT 250 WORDS)

Manganese content of large-volume parenteral solutions and of nutrient additives

Manganese (Mn) was analyzed by flameless atomic absorption spectrophotometry in a variety of commercially produced solutions and additives commonly used in total parenteral nutrition (TPN). The amount of Mn in preparations tested varied among manufacturers and among lots. It was generally present in very small amounts with amino acid preparations supplying the major portion in the TPN formulas. Among amino acid solutions, Aminosyn 10% had the highest Mn content (5.2-17.0 micrograms/liter) with Veinamine 8%, FreAmine II, 8.5%, Travasol 10%, and Nephramine having less than 6.7 micrograms/liter. Other large volume parenterals contained appreciably less Mn, eg, Dextrose 50% had 0.64-2.5 micrograms/liter. Some of the additives were high in Mn, eg, potassium phosphate--280 micrograms/liter, magnesium sulfate 50%--up to 225 micrograms/liter, and Berocca C--245.8 micrograms/liter but their actual contributions to daily TPN intake was no more than 3.3 micrograms. The calculated Mn content in TPN formulas with varying source materials ranged from 8.07-21.75 micrograms per total daily volume. These values agreed with those obtained from analysis of actual TPN solutions. The values for 10% Intralipid and 20% Liposyn were 0.5 and 3.0 micrograms/liter, respectively.

Iron supplementation of total parenteral nutrition: a prospective study

A prospective study to evaluate the iron dosage needed to restore serum iron levels was performed on patients receiving prolonged total parenteral nutrition (TPN). Intravenous iron intakes of 0, 25, 87.5, and 175 mg/wk were sequentially studied. No untoward responses were seen in 42 patients studied for 2758 patient days. When compared to pre-TPN levels, serum iron levels increased significantly with increasing iron dosage (p less than 0.002). In every single patient at the two highest dosage levels, serum iron levels at 3 wk rose from the pre-TPN level. Hemoglobin, reticulocyte count, transfusion requirement, total iron binding capacity, and red cell indices were not affected by iron dosage. There was no increased incidence of sepsis in patients who received increasing iron dosage. Both the 87.5 and 175 mg/wk iron doses increased serum iron levels from pre-TPN values, but the highest dose increased serum iron levels above the normal range in 80% of patients after 3 wk of administration allowing us to recommend the 87.5 mg/wk dose.

A study of the percutaneous absorption from topically applied zinc oxide ointment

The systemic absorption from topical applications of 40% zinc oxide ointment was investigated in a series of healthy subjects (phase one) and in patients receiving total parenteral nutrition (phase two). In the first phase, six subjects completed a controlled, cross-over trial involving 3 hourly serum sample determinations for zinc concentration following a massive application of 40% zinc oxide ointment and plain petrolatum ointment. There was a mean increase in serum zinc from 107.3 +/- 5.32 to 116.1 +/- 5.02 micrograms/dL 1 hr after application of 40% zinc oxide ointment (p greater than 0.05). Three patients receiving total parenteral nutrition completed phase two of the protocol in which 40% zinc oxide ointment was applied daily to a specified area of the thigh. Analysis of these patients' serum revealed that the zinc concentrations remained relatively constant over the 10-day study period. These findings suggest that topical applications of 40% zinc oxide ointment do not result in significant absorption. This study serves as a starting point for further investigations.

Net metabolic changes of zinc, copper, nitrogen, and potassium balances in skeletal trauma patients

Zinc, copper, nitrogen, and potassium balances of 10 male skeletal trauma patients were determined over 5-6 days each. Nutrition consisted of electrolyte/glucose and/or blood/blood product infusions. Patients were started on balance studies within 24 hr following injury. Zinc and copper were analyzed by atomic absorption while nitrogen was measured by the microKjeldahl technique and potassium by flame photometry. The mean daily balances for these patients were -1563 micrograms zinc, -266 micrograms copper, -20.0 g nitrogen and -29 mEq potassium for 5 patients receiving electrolyte/glucose infusions and +1273 micrograms zinc, +322 micrograms copper, -12.9 g nitrogen, and -26 mEq potassium for 5 patients receiving blood/blood products in addition to electrolyte/glucose. Routine daily maintenance supplementation of 2 mg zinc and 2 mg copper is recommended for skeletal trauma patients on electrolyte/glucose and those on electrolyte/glucose with blood/blood products intravenous infusions. Further balance studies are necessary to ascertain the level of zinc and copper supplementation needed by skeletal trauma patients receiving different nutritional support.

A standardized approach to parenteral nutrition for the geriatric patient

Parenteral nutrition can be a useful therapeutic and prophylactic tool in managing some geriatric patients who present with nutritional deficiencies that accompany acute and chronic diseases. An outline is given of recommended procedures, e.g., solutions, dosages, indications, and contraindications. The techniques described permit a standardized approach to parenteral nutrition for most patients.

Trace element balance in adults receiving parenteral nutrition: preliminary data

There have been many recommendations regarding trace element needs of adults receiving total parenteral nutrition. Balance studies for zinc, copper, manganese, chromium, selenium, and molybdenum were carried out in 3 critically ill patients in an intensive care unit. Results indicate that the need for zinc was great in them, but that for copper and manganese was lower. Small negative chromium and selenium balances were observed. Molybdenum, iron, cobalt, and iodine balances were attempted but proved difficult to interpret. The requirement of each trace element varied from patient to patient, and was influenced by the presence of gastrointestinal fluid loss and renal function.

Parenteral nutrition in severely burned children

In adults supplemental parenteral nutrition (PN) is advisable in burns over 40% especially when weight loss exceeds 10% of body weight. In children with smaller reserves and higher requirement of proteins and energy no rigid scheme for parenteral supplementation is used at our unit. In a young infant it may be added already at a 20-30% deep burn, especially with connected gastrointestinal tract problems, infection etc. Metabolic and protein requirements are estimated 50-100% in addition to their normal needs. Hypertonic glucose (gradually increased from 20-40%), covered with insulin in the early phase, is used as source of carbohydrates. L-amino acid mixture containing the "pediatric essential amino acids" histidine and cysteine is given as a nitrogen source. 20% Intralipid is given in a gradually increased amount of 2-4 g/kg per day to provide calories and essential fatty acids. Among electrolytes K, Ca, P and Mg must be added. Increased amounts of vitamin C and folate are needed by burned children. Vitamin E is also required during prolonged lipid administration. Trace elements (Zn. Fe, etc.) are supplied orally or i.v. with special solutions or fresh plasma infusions. Our experience with parenteral nutrition in severely burned children will be presented. There were no severe metabolic side-effects but sepsis represented the major problem. The concomitant heat preservation by warming the room and use of infra-red heaters is emphasized.