Very prolonged use of TPN can lead to vitamin deficiencies. The usual vitamin requirements can be met by provision of the following: MVI Peds - 3 cc/day for infants < 3 kg MVI Peds - 5 cc/day for children < 11 years MVI Adult - 10 cc/day for children >= 11 years Trace element deficiencies can also occur with prolonged TPN. The standard order for trace elements is: Pediatric trace elements - 0.1 cc/kg/day for children < 30 kg Adult trace elements - 3 cc/day for children > 30 kg In addition , consider adding selenium in patients on prolonged TPN (2-3 microgm/kg/day for children under 5, 30 mcg/day for older children). Carnitine (10-20 mg/kg/day) and molybdenum (0.25 mcg/kg/day for prematures, neonates and infants, 0.1-0.25 mcg/kg/day for older children and adolescents) can also be given, but this is not routinely done. You should also consider adding zinc in patients with excessive GI losses. For those patients with hepatic insufficiency, change the daily trace elements to 1-2 times per week (newborns and infants) or hold altogether (older children and adults). This is because copper and manganese are excreted in the bile which can lead to toxicity in liver failure. If trace elements are held, you must add in zinc and chromium separately. Albumin is not routinely added to the TPN. Neither is insulin, although current literature suggests improved outcomes with tighter blood sugar control. If the patient is on IV Pepcid, add the current amount being given to the TPN bag, then discontinue the BID dosing once the TPN is hung. Return to Top of Page