Nutrition and

Wound Healing
Heidi Greenwaldt MS, RD, LD, CNSD

Objectives
Participant will be able to:
- Explain the correlation between nutrition status and skin breakdown. - List the nutrients shown to have benefit in prevention and treatment of wounds.

- Understand criteria and process used to refer patients with wounds for nutritional assessment.

Nutrition Status and Wounds

- Strong correlation between severe malnutrition and development of pressure ulcers
BMI <20 Albumin <3
[Mathus-Vliegen 2001]

- Nutrition status and recent intake can significantly alter wound healing response
With wt loss of 10% lean wt, the body fights the wound for nutrients, especially protein, and healing slows [Demling 1998] immune systems defenses tissue regrowth

- Compromised nutrition status affects

Average heal time for Stage III AFTER restoration of good nutrition status is 6 mo.

Complications with Loss of Lean Body Mass

% Loss Total LBM 10 20 30 Complications Decreased immunity, Increased infections Decreased healing, weakness, infection Associated Mortality % 10 30

Too weak to sit, 50 pressure ulcers, pneumonia, no healing Death, usually from pneumonia 100

40

Protein Labs
-Albumin and Prealbumin are NOT good indicators of nutrition status in critically ill patients -Albumin and Prealbumin indicate the severity of illness not of malnutrition -Labs are decreased with inflammation, ascites, liver disease

-Excessive protein intake/supplementation will not increase levels until inflammation is decreased

Key Nutrients in Wound Healing

- Calories - Protein
- Fluid

- Zinc - Vitamin C
- Vitamin A

Calories and Wound Healing

- General requirements:
25-35 kcal/kg unless Underweight 35 Obese <25 kcal/kg

- In general, about 15 calories/pound (30 calories/kg) needed to provide sufficient energy to prevent protein breakdown in non-obese.

Protein and Wound Healing

- Functions include
Collagen synthesis Epidermal cell proliferation Skin integrity Resistance to infection

- Deficiency is common in the elderly, hospitalized, and stressed

- Approximate requirement

1.2-1.5 gm/kg/day, or to gm/pound.

Fluid and Wound Healing

- Water makes up significant portion of blood and hydrates skin. - Need blood to be able to transport nutrients and oxygen to the wound. - Typical requirement 25-35 mL/kg or 1 mL/kcal - Many factors influence fluid needs

Research Limitations
-No human studies define the exact nutrients for optimal wound healing - Too many confounding variables in actual patients and to obtain a uniform study group with similar wound stage, size, location -Limited laboratory data acquired to identify vitamin/mineral deficiencies so empiric treatment is frequently employed. -Healing wounds vs preventing wounds from developing

Role of Micronutrients during Stages of Wound Healing

-Inflammatory

-Proliferative Angiogenesis, fibroblasts, collagen deposition Vitamins A, B6, & C, Cu, Fe, Mg, Zn

Macrophages, neutrophils, blood clotting, vasodilation Vitamins A & K

-Remodeling

Collagen maturation & stabilization, scar tissue matures Vitamin C, Cu, Fe, Zn

Vitamin C
- Functions
Necessary for collagen synthesis Enhances immune function

- Depressed levels found in elderly, smokers, and certain cancers [Ross 2002] - Recommended supplementation: 500-1000 mg/day for 2 weeks if deficiency suspected.

Vitamin A
- Stimulates differentiation in fibroblasts and collagen synthesis to quicken healing -Deficiency difficult to determine 5000-25000 International Units X 10 days - Supplementation recommended for patients on chronic or high dose steroids
-

Steroids adversely affect all phases of wound healing and increase risk of infection [Ross 2002]

Zinc
- Essential cofactor in protein synthesis and collagen formation - Patients at risk for deficiency:
Prolonged poor protein intake Malabsorption GI losses including: diarrhea, fistula, drainage

-Recommended supplementation: 50 mg/day for 2 wks

-Benefit when serum zinc <100-110 mcg/dL

- Excess zinc can cause impaired neutrophil and lymphocyte function and can cause copper deficiency

Other Supplements
Arginine Glutamine Hydroxymethlybutyrate (HMB)

associated with wound healing

Arginine
- Functions Precursor to nitric oxide and nucleotides Improves cell-mediated immunity Enhances production of fibroblasts and collagen - Increases IGF-1 (Insulin Like Growth Factor) level
hormone that promotes wound healing

- Studies suggest positive outcomes in post-op surgical wounds. - More clinical trials needed to determine efficacy in acute and chronic wound healing.

When and How to Use Arginine

- Should NOT be first line of defense - Consider for non-healing wounds after calorie and protein needs met - Therapeutic dose to promote healing is ~9 grams/day

Glutamine
- Functions
Regulates amino acid homeostasis Preferred energy source for rapidly multiplying cells of intestinal mucosa and immune system May stabilize the intestinal barrier, reducing risk of bacterial translocation and systemic inflammatory response [Neu 2002]

- Clinical trials of supplementation suggest benefit but remain inconclusive.

How and When to Use Glutamine

- This is NOT first line of defense - Indications are for patients with GI impairment and Immune deficiencies - Provide 15-30g/day or .57 gm/kg wt

-Hydroxy--methyl-butyrate
(HMB)
- Function - Substance derived from breakdown of amino acid leucine
Anti-catablic agent Used for reduction of muscle tissue breakdown

- Lack of clinical trials available

- Juven (Abbott Products), marketed for wound healing

Contains 7 gm arginine, 7 gm glutamine, 1.5 g HMB per packet

2009 NPUAP EPUAP Guidelines

-Assess pts with pressure ulcers (C) -Refer pt with pressure ulcer to RD (C) -Assess weight status (C)

-Assess eating independence & total intake (C)

-Encourage a balanced diet (B) -Provide supplements as needed (B) -Provide nutrition support as needed (C)
www.npuap.org

How Fairview Identifies Patients with Wounds and Nutrition Risk

- Patient Profile Nutrition Risk Screen on Admission
Nutrition Trigger: Non-Healing Wound/Pressure Ulcer

- Braden Risk Assessment

< 3 Nutrition Braden *Remember the RULE OF 3 - Average po intake <3 (<50%) over 3 meals and 3 days * Use critical judgment based on pt status

Nutrition Braden Consults

Appropriate -Pt on solid food po diet, skipping breakfast, soup for lunch, bites at dinner X 3 days Not Appropriate -NPO pts -Clear Liquid pts -Pts with good intake at lunch but poor intake at dinner x 1 day -Completing the Braden on evening/night shift after meals so marking the Nutrition section as 0

Role of Nutrition Services in Wound Healing

-Assessment -Intervention -Monitoring

Nutrition Assessment
- Chart Review
Diagnosis, PMH, wt loss hx, and stage of ulcer or severity of wound, potential macro- or micronutrient deficiencies

- Assess Nutrient Needs

- Assess ability to meet those needs per intake analysis - Review vitamin/mineral supplementation history

Nutrition Intervention
- Educate patient about high calorie/protein food sources -Start calorie counts if necessary - Recommend liberalized diet - Offer high calorie/protein supplements - Start vitamin/mineral supplementation

Nutrition Monitoring
-Calculate 3 day average intake per calorie counts and assess ability to meet needs -Determine if supplements sent are being consumed -Ensure adequate fluid needs being met -Maintain glucose control -Review WOC Nurses notes for wound progress -Assure Zinc is not exceeding 6 weeks of use - IF no progress in wounds, despite calorie and protein needs being met, consider alternative nutrition interventions

References
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Scholl et al. J Int Nursing 24(2):124-32. Mar-Apr 2001. Mathus-Vliegen. NCP 16:286-91, October 2001 Kohn et al. J Dermatology 27: 258-263, 2001 Russell, L. Br J Nursing 10(6):S42-S49. 2001 (supp) Casey G. Nursing Standard 17(23): 55-58. Feb 2003 Breslow et al. J Am Geriat Soc 41:357-62, 1993. Ter Riet et al. J Clin Epidemiol 48:1453-60. 1995. Ross. Support Line. 24(4): 3-9, August 2002. Malone. NCP 15:253-56, Oct 2000 Wicke et al. Arch Surg 135:1265-1270. Nov 2000. Kirk et al. Surgery 1993;114:155-60. Barbul et al. Surgery 1990;108:331-337 Williams et al. Annals of Surgery 236(3): 369-75. Heyland. NCP 17:267-72. Oct 2002 Suchner et al. Br J Nutr. Jan 2002, 87(supp 1): S121-32. Demling et al. Ostomy Wound Mgmt 1998;44(10):58-68 Mikulin. Ostomy Wound Mgmt Sept 2001, 47(9): 17-20 Brasseur et al. NCP 15:218-22. Oct 2000. Neu J, et al. Current Opinion in Clin Nutr & Metabolic Care 2002; 5(1):69-75. Thompson. NCP 20:331-347; June 2005.