Parenteral Nutrients and Formulations Manganese


Manganese has multiple roles in enzymatic functions throughout the body. While isolated manganese deficiency is rarely reported, there have been several reports of hypermanganesemia, leading to a recommen- dation that the manganese content of PN trace element packages be reduced.28


reduction or elimination of PN manganese should be considered in patients who have biliary or liver disease.


Copper


As with several other trace elements, copper functions as an enzymatic cofactor. Copper is also involved in central nervous system function.31 There have been reports of copper deficiency manifested as pancyto- penia when copper-free PN was used for prolonged periods of time.36 Because copper may accumulate in the hepatobiliary system, reduced


copper intake along with close monitoring should be considered in patients with hepatobiliary disease due to impaired excretion. Although a previous study recommended reducing the copper content of current trace element formulations, this has not been done as of the time of this writing.28


Chromium


Chromium functions as an enzymatic cofactor in metabolic reactions that are associated with glucose homeostasis and insulin resistance.30 Chromium is no longer included in multiple trace element preparations, as it is present in high enough concentrations as a contaminant from other PN components. Practitioners should consider adding chromium in PN above these levels in cases of glucose intolerance (refractory to insulin), hyperlipidemia, elevated plasma free fatty acids, and peripheral neuropathy, as these are signs of chromium deficiency.30


Aluminum


There is ongoing concern regarding the aluminum content of PN formulas. Patients at risk for aluminum toxicity include neonates and individuals with impaired renal function who require long-term PN. The packaging of some PN components, especially additives in glass vials, allows inherent aluminum contamination, making it difficult to accurately analyze the amount of aluminum in PN and to limit intake to acceptable levels. Because


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Because manganese is excreted through the biliary system,


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