Mette M Berger1, Alan Shenkin2, Anna Schweinlin3, Karin Amrein4, Marc Augsburger5, Hans-Konrad Biesalski6, Stephan C Bischoff7, Michael P Casaer8, Kursat Gundogan9, Hanna-Liis Lepp10, Angélique M E de Man11, Giovanna Muscogiuri12, Magdalena Pietka13, Loris Pironi14, Serge Rezzi15, Cristina Cuerda16. 1. Department of Adult Intensive Care, Lausanne University Hospital (CHUV), Lausanne, Switzerland. Electronic address: mette.berger@unil.ch. 2. Institute of Aging and Chronic Disease, University of Liverpool, Liverpool, UK. Electronic address: shenkin@liverpool.ac.uk. 3. Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany. Electronic address: anna.schweinlin@uni-hohenheim.de. 4. Medical University of Graz, Department of Internal Medicine, Division of Endocrinology and Diabetology, Austria. Electronic address: karin.amrein@medunigraz.at. 5. University Centre of Legal Medicine Lausanne-Geneva, Lausanne University Hospital and University of Lausanne, Geneva University Hospital and University of Geneva, Lausanne-Geneva, Switzerland. Electronic address: Marc.Augsburger@chuv.ch. 6. Institute of Nutritional Science, University of Hohenheim, Stuttgart, Germany. Electronic address: biesal@uni-hohenheim.de. 7. Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany. Electronic address: bischoff.stephan@uni-hohenheim.de. 8. KU Leuven, Department of Cellular and Molecular Medicine, Laboratory of Intensive Care Medicine, Leuven, Belgium. Electronic address: michael.casaer@uzleuven.be. 9. Division of Intensive Care Medicine, Department of Internal Medicine, Erciyes University School of Medicine, Kayseri, Turkey. Electronic address: kursatgundogan@gmail.com. 10. North Estonia Regional Hospital, Tallinn, Estonia. Electronic address: liis.lepp@gmail.com. 11. Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam Medical Data Science (AMDS), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands. Electronic address: ame.deman@amsterdamumc.nl. 12. Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università di Napoli (Federico II), Naples, Italy; United Nations Educational, Scientific and Cultural Organization (UNESCO) Chair for Health Education and Sustainable Development, Federico II, University, Naples, Italy. Electronic address: giovanna.muscogiuri@gmail.com. 13. Pharmacy Department, Stanley Dudrick's Memorial Hospital, Skawina, Poland. Electronic address: magpietka@gmail.com. 14. Alma Mater Studiorum - University of Bologna, Department of Medical and Surgical Sciences, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Centre for Chronic Intestinal Failure - Clinical Nutrition and Metabolism Unit, Italy. Electronic address: Loris.pironi@unibo.it. 15. Swiss Nutrition and Health Foundation (SNHf), Epalinges, Switzerland. Electronic address: serge.rezzi@nutritionhealthfoundation.ch. 16. Departamento de Medicina, Universidad Complutense de Madrid, Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain. Electronic address: cuerda.cristina@gmail.com.
Abstract
BACKGROUND: Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. Recent research has shown the importance of MNs in common pathologies, with significant deficiencies impacting the outcome. OBJECTIVE: This guideline aims to provide information for daily clinical nutrition practice regarding assessment of MN status, monitoring, and prescription. It proposes a consensus terminology, since many words are used imprecisely, resulting in confusion. This is particularly true for the words "deficiency", "repletion", "complement", and "supplement". METHODS: The expert group attempted to apply the 2015 standard operating procedures (SOP) for ESPEN which focuses on disease. However, this approach could not be applied due to the multiple diseases requiring clinical nutrition resulting in one text for each MN, rather than for diseases. An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL. The search focused on physiological data, historical evidence (published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations. RESULTS: There was a limited number of interventional trials, preventing meta-analysis and leading to a low level of evidence. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90% of votes. Altogether the guideline proposes sets of recommendations for 26 MNs, resulting in 170 single recommendations. Critical MNs were identified with deficiencies being present in numerous acute and chronic diseases. Monitoring and management strategies are proposed. CONCLUSION: This guideline should enable addressing suboptimal and deficient status of a bundle of MNs in at-risk diseases. In particular, it offers practical advice on MN provision and monitoring during nutritional support.
BACKGROUND: Trace elements and vitamins, named together micronutrients (MNs), are essential for human metabolism. Recent research has shown the importance of MNs in common pathologies, with significant deficiencies impacting the outcome. OBJECTIVE: This guideline aims to provide information for daily clinical nutrition practice regarding assessment of MN status, monitoring, and prescription. It proposes a consensus terminology, since many words are used imprecisely, resulting in confusion. This is particularly true for the words "deficiency", "repletion", "complement", and "supplement". METHODS: The expert group attempted to apply the 2015 standard operating procedures (SOP) for ESPEN which focuses on disease. However, this approach could not be applied due to the multiple diseases requiring clinical nutrition resulting in one text for each MN, rather than for diseases. An extensive search of the literature was conducted in the databases Medline, PubMed, Cochrane, Google Scholar, and CINAHL. The search focused on physiological data, historical evidence (published before PubMed release in 1996), and observational and/or randomized trials. For each MN, the main functions, optimal analytical methods, impact of inflammation, potential toxicity, and provision during enteral or parenteral nutrition were addressed. The SOP wording was applied for strength of recommendations. RESULTS: There was a limited number of interventional trials, preventing meta-analysis and leading to a low level of evidence. The recommendations underwent a consensus process, which resulted in a percentage of agreement (%): strong consensus required of >90% of votes. Altogether the guideline proposes sets of recommendations for 26 MNs, resulting in 170 single recommendations. Critical MNs were identified with deficiencies being present in numerous acute and chronic diseases. Monitoring and management strategies are proposed. CONCLUSION: This guideline should enable addressing suboptimal and deficient status of a bundle of MNs in at-risk diseases. In particular, it offers practical advice on MN provision and monitoring during nutritional support.
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