By: Jessica Steinmetz

Pressure Ulcers and Nutritional Supplements: Recommendations

for Use

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]

Supplemental Nutrition Intervention: Macronutrients

Calories. Energy. Carbohydrates. Protein.

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]

Supplements, Recommendations for Use

Arginine. Glutamine. Vitamins A, E, C. Zinc. Whey protein.

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]

Nutrition/ Supplemental Goals

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.