Current Anaesthesia & Critical Care 21 (2010) 49
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Current Anaesthesia & Critical Care
journal homepage: www.elsevier.com/locate/cacc
POINTS OF VIEW: NUTRITION
Trace elements – Commentary
Michelle Hayes
Magill Department of Anaesthesia, Intensive Care Medicine and Pain Management, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, United Kingdom
See Article, page 44.
This is a timely review, documenting the important subject of
trace element measurement and replacement in the critically ill
population. As stated in this review, they are rarely considered in
the day-to-day management of the critically ill patient.
Trace elements are essential nutrients with a large range of
functions. Deficiencies do occur, not only because of pre-morbid
chronically low levels but also due to increased losses through the gut,
urine and skin during critical illness. Trace element deficiencies
appear to be most severe in those patients who suffer major burn
injuries where losses of trace elements through burn wound exudate
are significant. These may delay wound healing, which together with
graft failure is a major issue after a burn injury. In this particular group
of patients it may not only just be necessary to meet normal trace
element requirements, but it is also possible that in large burns,
pharmacological manipulation (i.e. to above recommended daily
requirements) may have some morbidity and mortality benefit.
It is important however, to remember that trace elements may
be toxic and prolonged replacement of high doses may be
E-mail address: michelle.hayes@chelwest.nhs.uk
0953-7112/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cacc.2009.08.005
deleterious. This review clearly documents these issues. Some trace
elements such as aluminium are elevated after severe burn injuries
and attempts to minimise aluminium loading are necessary to
hasten the patient’s skeletal recovery.
One of the problems in the measurement of trace elements is
that they are bound to protein carriers, so static measurements may
not be representative and can be misleading. Moreover, replace-
ment in those patients with hypoproteinaemia may be futile, as the
trace element may not be delivered to the tissues.
In summary, there is little evidence for giving pharmacological
doses of trace elements to burns patients despite this being
common practice in many units. There is insufficient evidence to
make any recommendations in a general critically ill patient group.
Common sense suggests that treatment should be directed at
correcting deficiencies, which interestingly may often be possible
with standard nutritional therapy.
Further work needs to be carried out to establish optimal doses
and duration of treatment especially in burns patients.