|Nielsen, Forrest - Frosty|
Submitted to: Journal of Parenteral and Enteral Nutrition
Publication Type: Peer Reviewed Journal
Publication Acceptance Date: 11/9/2007
Publication Date: 3/15/2008
Citation: Klein, C.J., Nielsen, F.H., Moser-Veillon, P.B. 2008. Trace Element Loss in Urine and Effluent Following Traumatic Injury. Journal of Parenteral and Enteral Nutrition. 32(2):129-139.
Interpretive Summary: Few data are available to establish recommendations for trace element intake during critical illness when nutrient intake is by intravenous feeding only (total parenteral nutrition or TPN) and when loss of kidney function requires blood filtration. Thus, the loss of two essential trace elements (manganese and selenium), three elements that animal studies suggest may influence wound healing or recovery from trauma (boron, nickel, and silicon), were determined in male trauma patients receiving TPN. The men were divided into groups with normal kidney function, and with kidney failure treated with two different types of blood filtration regimens. Analysis of urine, effluent from artificial kidneys, and TPN solutions indicated that trauma patients receiving TPN excrete substantial nickel and selenium, but little boron, manganese and silicon in the urine. Dialysis of trauma patients with kidney failure increased the loss of boron, manganese, nickel, and silicon. The results indicated that the amounts of manganese usually provided by TPN (60-300 micrograms per day) are excessive, and the amounts of selenium usually provided by TPN (20-60 micrograms per day) may be inadequate. In addition, the findings suggested that boron and silicon provided only by contamination of TPN solutions might not be in amounts that would be beneficial for recovery from trauma. The basis or consequences for above normal loss of nickel by trauma patients need to be determined. This study indicates a need for further studies about the optimal intake of trace elements by trauma patients.
Technical Abstract: Background and Purpose: Few data are available to establish recommendations for trace element intake during critical illness. This study quantified loss of several elements and assessed the adequacy of manganese and selenium in total parenteral nutrition (TPN). Methods: Men receiving TPN after trauma were grouped by renal status: adequate (POLY; n=6); or acute failure with hemofiltration (CVVH; n=2) or hemodiafiltration (CVVHD; n=4). TPN supplied 300 µg/d manganese and 60 µg/d selenium. Urine and effluent (from artificial kidneys) were collected for three days and analyzed for boron, manganese, nickel, and silicon using inductively coupled plasma atomic emission spectrometry and for selenium using atomic absorption spectrometry. Results: POLY manganese and selenium excretion averaged ± SD 7.9±3.3 µg/d and 103.5±22.4 µg/d, respectively. All elements, except selenium, were detected in dialysate (prior to use). CVVHD effluent contained 3.5 and 7.3 times more manganese and nickel than CVVH ultrafiltrate, respectively. Loss of manganese averaged 2.6%, 21%, and 73% of TPN amount for POLY, CVVH, and CVVHD groups, respectively. Discussion: Minimal loss of manganese compared to the amount of TPN suggests excessive amounts are retained. POLY patients excreted more selenium than was in TPN, indicating negative balance. POLY losses of boron and silicon were less than that published for healthy adults, reflecting less-than-typical intake whereas loss during CVVH was in the normal reference range, possibly due to boron contamination of replacement fluids. All patients lost more nickel than amounts published for healthy adults. Conclusion: Current guidelines of 60-100 µg/d of parenteral manganese may be excessive for trauma patients. The uptake of manganese and nickel from contaminants in CVVHD dialysate should be investigated.