Australasian society for parenteral and enteral nutrition (AuSPEN) adult vitamin guidelines for parenteral nutrition.

BACKGROUND AND OBJECTIVES: This work represents the second part of a progressive review of AuSPEN's 1999 Guidelines for Provision of Micronutrient Supplementation in adult patients receiving parenteral nutrition. METHODS AND STUDY DESIGN: A systematic literature review was undertaken and recommendations made based on the available evidence and with consideration to specific elements of the Australian and New Zealand (NZ) practice environment. The strength of evidence underpinning each recommendation was assessed. A multidisciplinary steering committee and external reviewers provided feedback on the guidelines. RESULTS: On review of the available literature it appears that the parenteral multivitamin preparations presently available in Australia and NZ are to sufficient avoid deficiency without causing toxicity in most clinical situations for adults receiving PN when provided regularly as part of the PN prescription. Vitamin D is the most vulnerable vitamin for the Australian and NZ PN population. CONCLUSIONS: Vitamins are an essential component of PN and should be provided from commencement for all patients receiving PN. With the exception of vitamin D, which is recommended to be monitored annually, routine monitoring of vitamin levels is unlikely to be necessary in patients receiving regular parenteral multivitamin preparations. Clinical judgement is an important element when assessing, prescribing and monitoring patients receiving PN. Areas requiring further research have been identified.

Recommendations for Manganese Supplementation to Adult Patients Receiving Long-Term Home Parenteral Nutrition: An Analysis of the Supporting Evidence.

INTRODUCTION: Manganese (Mn) toxicity is often observed in adult patients receiving long-term home parenteral nutrition (HPN), and differing recommendations on the safe level of Mn administration to these patients have been made in the literature over the past 10 years. METHODS: This systematic review used the National Health and Medical Research Council (NHMRC) evidence hierarchy to assess the design and strength of individual studies (high I to low IV) and the overall grade of evidence (grade A high to grade D low). RESULTS: Eight studies met the inclusion criteria. Levels of evidence ranged from high (NHMRC II) to mid-level (III-3). A widespread recommendation in the literature for patients receiving long-term HPN is 55 µg (1 µmol) Mn/d. CONCLUSION: The recommendation of 55 µg (1 µmol) Mn/d is of moderate-strength evidence (NHMRC B grade). There is limited evidence to support not supplementing Mn to patients receiving long-term HPN. Further intervention studies providing high-level evidence (II and above) are required to determine the safety of not supplementing Mn to all patients receiving long-term HPN.

Australasian Society for Parenteral and Enteral Nutrition guidelines for supplementation of trace elements during parenteral nutrition.

BACKGROUND: This work represents the first part of a progressive review of AuSPEN's 1999 Guidelines for Provision of Micronutrient Supplementation in Adult Patients receiving Parenteral Nutrition, in recognition of the developments in the literature on this topic since that time. METHODS: A systematic literature review was undertaken and recommendations were made based on the available evidence and with consideration to specific elements of the Australian and New Zealand practice environment. The strength of evidence underpinning each recommendation was assessed. External reviewers provided feedback on the guidelines using the AGREE II tool. RESULTS: Reduced doses of manganese, copper, chromium and molybdenum, and an increased dose of selenium are recommended when compared with the 1999 guidelines. Currently the composition of available multi-trace element formulations is recognised as an obstacle to aligning these guidelines with practice. A paucity of available literature and limitations with currently available methods of monitoring trace element status are acknowledged. The currently unknown clinical impact of changes to trace element contamination of parenteral solutions with contemporary practices highlights need for research and clinical vigilance in this area of nutrition support practice. CONCLUSIONS: Trace elements are essential and should be provided daily to patients receiving parenteral nutrition. Monitoring is generally only required in longer term parenteral nutrition, however should be determined on an individual basis. Industry is encouraged to modify existing multi-trace element solutions available in Australia and New Zealand to reflect changes in the literature outlined in these guidelines. Areas requiring research are highlighted.