by: jessica steinmetz pressure ulcers and nutritional supplements: recommendations for use
TRANSCRIPT
What are Pressure Ulcers?Areas of necrosis and ulcerationOccur when tissues are compressed
between a bony prominence and a hard surface
Etiology: PressureFrictionShearing forcesCan result from pressure alone or
combination
Risk Factors for Pressure UlcersOld age
Reduced subcutaneous fat
Decreased capillary flow
ImmobilityCo-morbidities
Impaired circulationImmobilizationPoor nutrition status
DehydrationDiabetesCardiovascular disease
Incontinence
PUs can develop in as little as 3 to 4 hoursImmobilized trauma
patientsWorsen when skin
is overly moist and maceratedPerspiration Incontinence [1]
Clinical Assessment – Predicting Risk
Braden ScaleThe patient is evaluated in
6categories: Sensory perceptionMoistureActivityMobility NutritionFriction and shearPressure sore risk
increases as thescore decreases: 15–16 = mild risk12–14 = moderate risk< 12 = serious risk
Wound Staging
Normal Tissue•Intact skin, redness localized usually over bony prominence•May be painful, firm, soft, warm or cool. [3]
Wound Staging (cont.)
•Partial thickness and loss of dermis•Shallow open ulcer with red pink wound bed•Intact or open/ruptured blister [3]
•Full thickness tissue loss•Subcutaneous fat may be visible•Slough may be present [3]
Wound Staging (cont.)
•Full thickness tissue loss •Exposed bone, tendon or muscle•Slough or eschar may be present [3]
•Full thickness tissue loss•Base of ulcer cover in slough and/or eschar [3]
Treatment for Pressure UlcersReduce pressure!Direct care of ulcerManagement of pain,
infection, undernutrition
Sometimes adjunctive therapy or surgery
Treatment requires multiple simultaneous elements. [10]
Calories/EnergyEssential for pressure
ulcer healingPromotes anabolismNitrogen and
collagen synthesis, healing
Increased kcals needed for hypermetabolism [4]
Carbohydrates:Glucose is the main
fuel source for collagen synthesis [4]
Calorie needs:30 - 35 kcal/kg
body weight/day.35 - 40 kcal/kg
body weight/dayPatients who are
underweight or losing weight. [5]
ProteinRole in wound
healing:Synthesis of ulcer-
healing enzymesCell multiplicationCollagen and
connective tissue synthesis
Promote positive nitrogen balance
Recommendations:1.2-1.5 g/kg
Limitations:Protein levels as high
as 2.0 g/kg may not increase synthesisMay contribute to
dehydration in elderly [4]
Arginine Function:
Stimulates insulinPromotes transport of
amino acids into tissue cells
Supports formation of protein [4]
Normally produced in adequate amounts in the bodyStress, illness may
increase amounts needed [14]
Recommendation for use:
A 30-day trial period is suggested Adequate kcal and
protein intake must be first priority. [14]
Maximum safe dosage not established.Additional research
needed [4]
Arginine Supplement ExamplesArigment AT
Advanced therapy for chronic wounds
ArgimentAdvanced therapy
for staged woundsArginTein
Nutrition support for Stage I and II pressure ulcers
Ensure, Boost, Slim-Fast or Carnation Instant Breakfasts have been known to be used if Arginine supplements are not available [14]
Glutamine SupplementationFunction:
Most abundant amino acid in the body
Fuel source for fibroblasts and epithlial cells
Injury, surgery, infection and prolonged stress can lower gluatmine levelsIn these cases,
supplementation may be helpful
Crucial role in stimulating the inflammatory immune response occurring early in wound healing
Recommendation for use:Typically available in 500
mg tabletsAvailable by itself or as
part of a protein supplementPowder, capsule, tablet,
liquidSafe maximum dose is
0.57 g/kg
Glutamine Supplementation (cont.)
Efficacy debated:One study shows oral
Glu supplementation to improve wound breaking strength, increase mature collagen [16]
Others show supplemental Glu to not improve wound healingAdditional research
also needed [4]
Resource Glutasolve 15g L-Glutamine
Restore-X packets 10g Glutamine
Impact Recover5g L-Glutamine
Dietary sources:Beef, pork, poultry Milk, yogurt, ricotta
cheese, cottage cheeseRaw spinach, raw
parsley, and cabbage
Vitamin SupplementationVitamin A:
Deficiency results in: Impaired wound
healing Alteration in immune
function, may increase likelihood of wound infections
Supplementation is typically not strongly justified [12]
Potentially toxic
Vitamin E:Anti-oxidant, anti-
inflammatory properties
Effect in healing acute/chronic wounds is controversialFurther research is
needed in humans [11]
Vitamin Supplementation (cont.)
Vitamin C:Deficiency associated with delayed wound healing
Supplementation enhances wound healing
The Agency for Health Care Research and Quality recommends: Stage I and II – 100mg - 200mg per dayStage III and IV - 1,000mg - 2,000mg per day [12]
ADA Evidence Analysis Library rates the previous Vitamin recommendation as Conditional
Zinc Supplementation
Function:Cellular metabolismProtein synthesisMaintains integrity of
skin and mucosal membranes [8]
Supplemental forms:Zinc gluconateZinc sulfateZinc acetate
Percentage of elemental zinc varies by form [8]
Supplementation:ZnSo4 220mg (50mg
elemental Zinc) 2x/day recommended as a standard oral replacement [12]
May be effective for treating leg ulcers in patients with low serum levels [8]
No evidence that general use in patients with chronic leg ulcers is effective [8]
Zinc Supplementation (cont.)
High-dose supplements may be limited to 2-3 weeks
May adversely affect:Copper status Immune response Lipid profiles GI side effects
Important to minimize risk of adverse effects unless justified by ongoing losses
Whey SupplementationWhey definition:
Dairy product containingmilk serum proteins
Function:May increases
glutathione synthesis and cellular antioxidant defenseGlutathione =
combination of cysteine, glycine and glutamine
Efficacy:Long-term effects
of whey for wound healing unknownNeeds further
research [13]
Whey Supplement Example
ProNutraHigh risk patients susceptible to: Muscle wasting, stage I & II pressure ulcers,
PEM, protein malabsorption, or compromised immune systems: 1 serving (1 bottle) per day is recommended.
Stage III & IV pressure ulcers or patients with severe PEM: 2 servings (2 bottles) per day are recommended.
For long term maintenance 1 serving (1 bottle) 2 or 3 times per week
ProNutra may be added to oral and tube-administered enteral products. [9]
Identifying PEMAssessing malnutrition is important for
determining the use of supplements
Markers for identifying PEM in patients with pressure ulcers
Unintentional weight loss of ≥ 5% in the previous 30 days or of ≥10 % in the previous 180 days
Weight >80% of idealSerum albumin level <3.5 g per dL (35 g per L)*Prealbumin level <15 mg per dL (150 mg per L)*Transferrin level <200 mg per dL (2 g per L)Total lymphocyte count <1,500 per mm3 (1.50 ×
109 per L) [7]
Nutrition Goals for Prevention of PU’s
Making a plan to improve nutritional status/preventing pressure ulcers
1. Identify and correct factors compromising protein/ calorie intake
2. Consider supplements/support for nutritionally those compromised patients.
3. Offer and encourage hydration4. MVI with minerals per physician’s order or
recommend when necessary. [11]
ConclusionAdequate nutrition and a basic MVI are
typically the first line of defenseCalorie and protein intakes need to be
adequate for supplementation to be effective
There is no research to justify administration of vitamin/mineral supplements that are above the US RDI [4]
Additional research is needed for the definitive justification for the continual use of supplements in wound healing
Resources1. Pressure Ulcers. Merek Manual. Accessed July 10, 2012
http://www.merckmanuals.com/professional/dermatologic_disorders/pressure_ulcers/pressure_ulcers.html?qt=pressure ulcers&alt=sh
2. NPUAP Free Resource Category/Staging Illustrations: http://www.npuap.org/resources.htm
3. Image Reference : http://www.npuap.org/pr2.htm
4. Dorner B, Posthauer ME, Thomas D. The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper.2009 NPUAP Nutrition White Paper 1. National Pressure Ulcer Advisory Panel http://www.npuap.org/Nutrition%20White%20Paper%20Website%20Version.pdf
5. What is the Current Recommendation for Vitamin and Mineral Supplementation for Pressure Ulcers. Academy of Nutrition and Dietetics.2008. Accessed July 10, 2012. http://www.eatright.org/Public/content.aspx?id=5825&terms=pressure+ulcers
6. Heyman H, Van De Looverbosch DE, Meijer EP, Schols JM. Benefits of an oral nutritional supplement on pressure ulcer healing in long-term care residents. J Wound Care 2008 Nov;17(11):476-8, 480. Source: OCMW Nursing Homes, Antwerp, Belgium. http://www.ncbi.nlm.nih.gov/pubmed/18978686.
7. Bluestein D, Javaheri A. Pressure Ulcers: Prevention, Evaluation, and Management. Am Fam Physician. 2008 Nov 15;78(10):1186-1194. Accessed July 10, 2012. http://www.aafp.org/afp/2008/1115/p1186.html
8. Office of Dietary Supplements. Zinc. National Institute of Health. Accessed July 11, 2012. http://ods.od.nih.gov/FactSheets/Zinc/
9. Pronutra. Drugs.com. Accessed July 11, 2012. http://www.drugs.com/drp/pronutra-protein-supplement.html
10. Image Reference: Wounds International, Accessed July 12, 2012 http://cms2.selesti.com/media/PUAP-poster.gif
11. Pressure Ulcer Prevention Points. National Pressure Ulcer Advisory Panel. 2007. Accessed July 12, 2012. http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-prevention-points/
Resources12. Recommendations Summary, Spinal Cord Injury Assessment of Nutritional Needs for Pressure Ulcer
Academy of Nutrition and Dietetics. Evidence Analysis Library. Accessed July 12, 2012 http://www.adaevidencelibrary.com/template.cfm?template=guide_summary&key=2378&auth=1
13.Velioglu Ogünç A, Manukyan M, Cingi A, Eksioglu-Demiralp E, Ozdemir Aktan A, Süha Yalçin A. Dietary whey supplementation in experimental models of wound healing. Int J Vitam Nutr Res. 2008 Mar;78(2):70-3. Accessed July 13, 2012. http://www.ncbi.nlm.nih.gov/pubmed/18791975
14.Grieger L. Nutrition and Wound Care. Today’s Dietitian. Vol. 11 No. 8 P. 12 August 2009 Issue Accessed July 15, 2012. http://www.todaysdietitian.com/newarchives/072709p12.shtml.
15. Glutamine. University of Marlyand Medical Center. Accessed July 15 2012. http://www.umm.edu/altmed/articles/glutamine-000307.htm#ixzz20hU84Phx
16. Guo S. Di Pietro L.A. Factors Affecting Wound Healing J Dent Res. 2010 March; 89(3): 219–229.