Parenteral aluminum loading in critical care medicine. Part II: Response to aluminum load from long-term parenteral nutrition.

Abstract

Evaluation of the iatrogenic aluminum load by aluminum-contaminated nutritive infusion solutions in long-term total parenteral nutrition (TPN). 16 consecutive patients (6 children, 10 adults) who had to undergo total parenteral nutrition for more than one month. Three of them were from a home parenteral nutrition program. The duration of TPN was up to 68 months. The parenteral aluminum load was calculated on the basis of the individual TPN programs. Six patients were exposed to an additional parenteral aluminum load in the course of intensive care. Comparative group: To establish a reference range, the serum aluminum concentrations were determined in 71 unloaded patients who had to undergo minor surgical procedures. ALUMINUM ANALYSIS: Strict adherence to a contamination-free sampling and processing technique. The aluminum determination was performed at the Hahn-Meitner-Institute Berlin by means of graphite-furnace atomic absorption spectrometry (GFAAS). The TPN-associated daily aluminum load was 3.5 +/- 0.4 micrograms/kg body weight (bw) in children and 2.2 +/- 1.8 micrograms/kg bw in adults. 59 +/- 6% of the intravenous aluminum load in children and 42 +/- 16% in adults was due to the highly contaminated small-volume calcium, inorganic phosphate, trace element and vitamin parenterals. The median serum aluminum concentration under TPN was 10.9 micrograms/l (range: 5.0-26.9 micrograms/l) and was thus 7.3 times higher than in the preoperative control group (median: 1.5 micrograms/l, 95% confidence interval: < 0.6-3.5 micrograms/l). Individual values ranged up to 36.8 micrograms/l. The aluminum intake of patients on parenteral nutrition in Germany is thus on occasion considerably above the ASCN/ASPEN recommendations for the limitation of intravenous aluminum loading (ASCN: American Society for Clinical Nutrition; ASPEN: American Society for Parenteral and Enteral Nutrition). The toxicological significance of parenteral aluminum loading is discussed. The results suggest that limits should be established for the Aluminum contamination of infusion solutions.