Manual of Clinical Nutrition

Parenteral Nutrition Support for Adults

Manual of Clinical Nutrition Management B- 55 Copyright © 2013 Compass Group, Inc.

Parenteral Intravenous Vitamins and Requirements
In 2000, the Food and Drug Administration (FDA) modified the requirements for adult intravenous
multivitamin products. The required amounts of ascorbic acid, thiamin, pyridoxine, and folic acid were
increased, and a requirement for vitamin K was added (37) (see Table B-4). With the addition of vitamin K to
these formulations, the prothrombin time and international normalized ratio of patients who receive
anticoagulant therapy should be closely monitored, and anticoagulant medication should be adjusted as
needed (20). One formula without vitamin K is available for patients whose prothrombin time or international
normalized ratio levels are difficult to manage (38). Weekly intravenous supply of 250 to 500 mcg
phylloquinone is adequate to preserve coagulation in PN patients (38). The adequacy of vitamin D in vitamin
preparations for PN may be inadequate for patients requiring long term PN as the daily PN infusion provides
a conservative amount of 200 to 400 IU (5 to 10 mcg) vitamin D. An effective method to ensure vitamin D
status for patients on PN long term is daily sunlight exposure (38). The vitamin and mineral requirements for
parenteral nutrition should be based on the Dietary Reference Intakes for the patient’s age and sex (38).
Clinicians should consider the deleterious impact of exceeding the FDA-recommended levels of parenteral
vitamins, and the potential harm that excessive vitamin intake has on other micronutrients, trace elements,
and immune status (38).

Table B-4: FDA Requirements for Parenteral Multivitamin Products (37)
Vitamin Amount^
Thiamin (B 1 ) 6 mg
Riboflavin (B 2 ) 3.6 mg
Pyridoxine (B 3 ) 6 mg
Cyanocobalamin (B 12 ) 5 mcg
Niacin 40 mg
Folic acid 600 mcg
Pantothenic acid 15 mg
Biotin 60 mcg
Ascorbic acid 200 mg
Vitamin A (retinol) 1 mg
Vitamin D 5 mcg
Vitamin E 10 mg
Vitamin K 150 mcg

Parenteral Intravenous Trace Minerals and Requirements
The ASPEN recommendations for daily parenteral intake of the trace elements zinc, copper, chromium, and
manganese were updated in 2004 (Table B-5) and remains the most current (16). These updated
recommendations include the addition of selenium supplementation (20 to 60 mcg/day) (16). Trace minerals
are available as single-entity and combination products in various concentrations for adults, children, and
neonates; products with a combination of trace minerals and electrolytes are also available (11,38). Other
elements that may be supplemented on an individualized basis include molybdenum, iodine, and iron. Iron
supplementation is generally not required for short-term parenteral nutrition, unless the patient is anemic.
Oral iron supplementation is the preferred route. However, if oral supplementation is infeasible, iron dextran
can be intravenously administered (38). The addition of iron to total nutrient admixtures is not recommended
because of compatibility problems (39). Patients with intestinal fluid losses (eg, patients with ostomies) may
require additional supplementation of zinc and chromium (see Table B-5). Patients with intestinal losses
require an additional 12 mg of zinc per liter of output from the small bowel and an additional 17 mcg of zinc
per liter of stool or ileostomy losses (16,40). Chromium requirements may also increase to 20 mcg/day with
gastrointestinal losses in adults (16).

Table B-5: Daily Parenteral Trace Element Supplementation for Adults (Dose per Day)

Trace Element

2004 ASPEN

Recommendation

Gastrointestinal

Losses

Zinca 2.5-5.0 mga Addb

Copper 0.3-0.5 mg 500 mcg/d

Chromium 10 - 15 mcg 20 mcgc

Manganese 60 - 100 mcg —

Selenium 20 - 60 mcg —

a Add 2 mg/day for hypermetabolic patients for a total of 6 to 12 mg/day.

bAdd 12 mg/L of small bowel losses, and add 17 mcg/kg of stool or ileostomy losses.