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Trace minerals in critically ill patients: a forgotten cause of delayed recovery?
Critical Care volume 8, Article number: P264 (2004)
The aim of this pilot study was to assess the possible deficiency of the standard nutrition protocol, based on the daily recommended doses (DRD) in the literature , in the surgical ICU for trace minerals. An intervention with extra supplements given in addition to the standard formula was evaluated.
A prospective, observational pilot study in a surgical ICU of a tertiary referral centre. Forty-eight intensive care patients with two or more organ failures were included in the study (APACHE II score 24.2 ± 7.9). All patients received total parenteral nutrition according to a standard protocol. Plasma measurements of manganese, selenium and zinc were performed before and after 7 days of extra supplementation with a commercial formula containing one DRD1 of each element (Addamel® N; Fresenius Kabi, 's-Hertogenbosch, The Netherlands). Twenty-five patients were also screened for copper and chromium levels and their response to supplements.
The overall daily caloric intake in the week before inclusion into the study was 1693 ± 841 kcal and during the study period 2211 ± 543 kcal (P = 0.002). Copper as a substantial element in the normal function of oxidative enzyme systems (so-called 'cupro-enzymes') and in plasma primarily bound to ceruloplasmine, an acute phase protein, is difficult to interpret in critically ill patients. However, levels at the start were normal (14.5 ± 6.3 μmol/l, n = 10.0–30.0 μmol/l) and could be raised significantly (17.4 ± 4.6 μmol/l, P = 0.004). Ceruloplasmin levels were within the normal range and did not change significantly over the study period (0.34 ± 0.11 g/l, n = 0.24–0.62 to 0.37 ± 0.10 g/l, P = 0.414). Manganese is part of the mitochondrial superoxide dismutase and important for the metabolic effects of vitamin K. In our population normal starting levels were found (30.5 ± 13.7 nmol/l, n = 2–37 nmol/l) and were raised significantly (37.0 ± 16.3 nmol/l, P = 0.021). Selenium as a co-factor in the erythrocyte glutathion peroxidase complex has a protective role against peroxides. (Very) low baseline levels were found (0.53 ± 0.22 μmol/l, n = 0.8–1.8 μmol/l) and the supplement, although double the DRD, could not normalize this (0.71 ± 0.28 μmol/l), but the improvement was statistically significant (P < 0.0001). Albumin as the transport protein for selenium was low and did not change significantly (20.9 ± 6.0 g/l, n = 35–50 to 21.1 ± 6.5 g/l, P = 0.959). Zinc metabolism and physiology are subject to debate. Zinc deficiency, however, is known for impaired wound healing, alopecia and immunologic dysfunctions. Almost all patients were deficient at the start (8.6 ± 3.6 μmol/l, n = 11.5–23.5 μmol/l), and then supplementation did result in significant improvement, but only just to normal levels (11.4 ± 2.6 μmol/l, P < 0.0001). Chromium is a cofactor in insulin metabolism and glucose utilisation. Plasma levels are difficult to assess, because of their biologic significance. However, starting levels were high (86 ± 52 nmol/l, n = 9.6–50 nmol/l) and were raised nonsignificantly (90 ± 45 nmol/l). The chromium-transporting protein transferrin was low and did not change significantly (1.3 ± 0.9 g/l, n = 2.0–3.5 to 1.3 ± 0.4 g/l, P = 0.475).
A significant percentage of ICU patients have trace mineral deficiencies, despite well-dosed parenteral (and/or enteral) feeding regimens. Low plasma levels are not unequivocal to interpret , but our results support a more prominent role for research and re-evaluation of the current recommended nutrition standards for ICU patients.
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van der Hoven, B., Schoonderbeek, J. & van Zoelen, C.G. Trace minerals in critically ill patients: a forgotten cause of delayed recovery?. Crit Care 8 (Suppl 1), P264 (2004). https://doi.org/10.1186/cc2731