Table 1.
Summary of trace elements (TEs) routinely supplemented in parenteral nutrition (PN) in North America.
| Trace Element | Signs and Symptoms of Deficiency | Signs and Symptoms of Toxicity | TE Monitoring | Conditions to Consider Dose Reduction | Conditions Requiring Increased Amounts |
|---|---|---|---|---|---|
| Copper | Pancytopenia, skeletal abnormalities, myocardial disease, depigmentation of hair, neurologic abnormalities | Acute: vomiting, diarrhea, acute kidney injury, hepatic necrosis, death Chronic: neurological disorders, renal insufficiency, and cirrhosis |
Ceruloplasmin, serum copper Levels be elevated in inflammation |
Cholestasis | High gastrointestinal (GI) losses (diarrhea, ostomy outputs, nasogastric suctioning), burn patients |
| Chromium | Glucose intolerance which may be refractory to insulin, hyperlipidemia, elevated plasma free fatty acids, weight loss, peripheral neuropathy | Not well documented | Plasma or serum chromium, although not a good indicator of tissue levels Levels may be reduced during acute illness |
Caution in renal insufficiency | Pregnant patients may have increased needs |
| Zinc | Eye and skin lesions, growth retardation, alopecia, and diarrhea | Acute: large oral doses can cause abdominal pain, vomiting, and diarrhea Chronic: high oral doses can cause low copper by interference with absorption |
Serum zinc Levels may be reduced during inflammation, especially sepsis |
N/A | Patients with high GI losses, sepsis, hypercatabolic states, and burns |
| Selenium | Cardiomyopathy, skeletal muscle myopathy, macrocytic anemia, and abnormalities in hair and nails | Hair and nail brittleness, peripheral neuropathy, skin rash, fatigue, and GI symptoms | Plasma/serum selenium Levels may be reduced during inflammation |
N/A | Critical illness, burns, continuous renal replacement therapy, high urine output, diarrhea/fistula output, multiple drains, and medications such as corticosteroids and statins |
| Manganese | Not well documented | Neuropsychiatric symptoms, Parkinson-like signs | Whole blood manganese, serum manganese Magnetic resonance imaging (MRI) can reveal deposition in the basal ganglia in toxicity |
Cholestasis | N/A |
N/A: not applicable.