“Dual-Route Feeding in Pressure Sore Patients”

Terry TING, MSc. Dietitian, Alice Ho Miu Ling Nethersole Hospital, HK

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Prince of Wales Hospital, HK

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Special Thank you to…• Dr. David Dai• Dr. Liu Kin Wah• Prof. L K Hung• Ms. Eliza Lau• Dr. May Tang• Dr. Bosco Ma• Dr. Wency Ho• Ms. Wai Yu

• Ms. Janet Lok• Ms. Phyllis Yau• Mr. Gordon Cheung• Mr. Kenny Cheng • Ms. Sandy Chang

• Division of Geriatrics, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong, SAR, CUHK

• Department of Orthopedic and Traumatology, Prince of Wales Hospital, Hong Kong SAR,CUHK

• Dietetics Department, Prince of Wales Hospital, Hong Kong, SAR ,CUHKACD2010

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Epidemiology of the pressure sore

• Older people are at high risk of developing pressure ulcers, as reflected in the fact that 70-73% of those develop pressure ulcer are over 65 years old. (Whitington et al 2000, Thomas 2006)

• Incidence of the pressure ulcer in hospitalized patient is 8.8 %. ( Baumgarten et al .2003,2006)

• 1.61 % for older patient in an outpatient setting. ( Margous et al.2003)

• The pressure sore incidence is 25.16% in Hong Kong Nursing Home.( Wai-yung Kwong et al 2009)ACD2010

Pressure Sores;Major burden on health care system

Joint Commission for Accreditation of Healthcare Organization ( JCAHO): estimates that there are between 1.3 and 3 millions adults with

pressure ulcer in the USA

• US$ 500 to US$40000 per ulcer depending on severity of the stage of the ulcer

• The annual cost of treating pressure ulcer in the UK was estimated to be approximately 750 millions pound

• In an Australian study, the– It was estimated that in 2001–2002 there was a median of 95,695

cases of pressure ulcer, with a median of 398,432 bed days lost,

• Opportunity costs of a median– AUS$285 million in Australian public hospitals.

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Before year 2008• Wound patients in HK receive nutrition support limited to

EN or TF only • Most of them NOT meeting their nutrition goals to promote

wound healing• EN – compliance and tolerance problems

– Not meeting goal intake (energy, protein, fluid)– Fluctuated intake– Poor appetite (mental, physical, and environmental factors)– Absorption & digestion problems due to ageing (Drozdowski L & Thomson AB, 2006)

• TF – tolerance Prof. Timothy Kwok, 2002,

– Diarrhea (33%) - 20% of diarrhea related to formula– Constipation (30%)– Nausea & Vomiting (20%) Critical Care Med 2002

– Tube Clogging (13%)– Absorption & digestion problems due to ageing (Drozdowski L & Thomson AB, 2006)

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Solution• PN is indicated and may allow adequate nutrition in

patients who cannot meet their nutritional requirements via the enteral route, and should be limited to situations when EN is contraindicated or poorly tolerated. (C)

• PN support should be instituted in the older person facing a period of starvation of more than 3 DAYS when oral or enteral nutrition is impossible, and when oral or enteral nutrition has been or is likely to be insufficient for more than 7-10 DAYS. (C)

(ESPEN Guidelines on Parenteral Nutrition 2009)ACD2010

Benefits of Dual Route Feeding• Gut immunity can be stimulated by partial EN• When tolerance to EN is limited by gut

dysfunction,• PN can deliver the required protein and calories,

as well as some therapeutic nutrients (e.g. Glu, Fish oil)

• Nutritional goal is easily achieved with patient• comfort and safety, cosmetic concerns• Consequences of inadequate nutrition are

avoided(Prof. J Asprer 2009)

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Case # 1

(Oral Diet + Nutrition Supplement*) x 75%

Oral Diet + Nutrition Supplements + PPN

Energy (Cal) ~1500Cal/d ~2300Kcal/d

Protein (g) ~75g/d ~ 114g/d

% Nutrients Met (Energy 80%, Protein 83%) (Energy 1156%, Protein 126%)

•Grade IV pressure sore•Male 59y, BW = 60kg (baseline Dec)•Poor oral intake ~ 800 Cal/d (w/o oral supplements)•Poor nutrition status – Ser alb 25, Hb 9.9, CRP 46.6•Est. Energy and protein requirement:

•2100Kcal & 90g protein/d (for grade IV pressure sore patient)

*Oral Nutrition Supplements: Perative (300 Cal, argirine containing formula)Resource Breeze (250 Cal, Orange flavor high protein supplement)

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Case # 2• Grade IV pressure sore• Female 85y, BW = 45.8kg (baseline Dec)• Poor oral intake ~ 500 Cal/d (w/o oral supplements)• Poor nutrition status – Ser alb 29, Hb 8.6, CRP 30.1• Est. Energy and protein requirement:

– 1600Cal & 70g protein/d (for grade IV pressure sore patient)

(Oral Diet + Nutrition Supplement*) x

50%

Oral Diet + Nutrition Supplements + PPN

Energy (Cal) ~800Cal/d ~1600Cal/d

Protein (g) ~50g/d ~89g/d (13g from glutamine)

% Nutrients Met (Energy 57%, Protein 70%)

(Energy 100%, Protein 128%)

*Oral Nutrition Supplements: Perative (300 Cal, argirine containing formula)Beneprotein 3 scoops/d (72Cal, 18g protein/d)

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Case reviewed before discharge

• Case # 1 (4 weeks)– BW 58.2kg (increased by 6%)– Ser alb 33, CRP 3– Oral intake improved ~ 1800Kcal/d

• Case # 2 (2 weeks)– Ser alb 35, Hb 11.1, CRP 4.8– BW nil– Oral intake improved (home diet taken)

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Our Case Study• A retrospective review• 11 Elderly patients Severe pressure ulcer ;Stage 3 and

Stage 4 (National Pressure Ulcer Advisory Panel, 1989)

• Referred to dietitian for nutrition support and further referred for Dual Route nutrition augmentation

• Objective: – To see any clinical improvement with PPN in additional to the

conventional treatment.– To see any relationship between albumin/CRP and PPN.– To see any relationship before and after PPN supplement.ACD2010

Inclusion criteria

1. Age above 65 year-old2. Chronic pressure sore refractory to conventional care

approach3. Dietitian assessment4. Patient who cannot meet their nutritional

requirements via the enteral route alone.5. Patient’s oral intake is likely insufficient for more than

7-10days6. Tube or Nasogastric tube feeding as nutritional

augmentation is refused by patient or next-of-kin.ACD2010

Exclusion Criteria

1. Lack of peripheral venous access

2. Diabetic patients with poor glycaemic Control

3. Terminal stage of illness

4. Severe demented patients;

5. Non-cooperative patientACD2010

Nutrition Assessments

• Anthropometric measurements• Biochemical data (alb, TLC, Pre-alb,

transferrin, CRP, RFT & LFT, Lipid profile etc…)

• Clinical History and Physical Exam• Dietary intake assessments (current intake)• Screening Tools (C-MUST, SGA, MNA)ACD2010

Nutrition Diagnosis

• Inadequate intake of energy and protein related to poor oral intake evidenced by:– Mean Energy 800kcal– Mean protein 35g

• High risk of Malnutrition related to inadequate oral intake and abnormal level of nutrition indicators evidenced by:– Inadequate intake according to est. nutrients

requirement– Low serum albumin & Hb, elevated CRP

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Protein requirement for Pressure Ulcer

• The recommended range of protein 1.2 to 1.5/kg BW (EPUAP 2009, AHCPR 2006)

• 1.5/kg BW to improved nitrogen balance (ESPEN 2009)

• 2.0 grams per kilogram body weight may not increase protein synthesis and may contribute to dehydration in the elderly (EPUAP 2009)ACD2010

Energy requirement for Pressure Ulcer

• Energy (America Dietetics Association 2009)

• Use indirect calorimeter to measure the energy need

• 30 - 40kcal/kgBW per day • Harris-Benedict times stress factor (1.2 for

stage II ulcer, 1.5 for stage III and IV ulcers) ~ usually over estimatedACD2010

Nutrition Intervention• Oral nutrition support or Tube feeding were given first• Dual Route feedings were then given to make up the

energy and protein deficits according to the inclusion criteria

• Oral Nutrition Support or Tube feeding– Diet texture and preferences modification– Enteral formula (e.g. Ultracal, Osmolite HN, Abound, Perative,

Glucerna, Ensure etc..)• PPN (Kabiven Peripheral or Nutrilflex Lipid Peri)

– +/- additives (Vitalipid-N, Soluvit-N, Addamel-N, Dipeptiven, Omegaven)

• Fluid requirement – 30ml/kg/BW or 1ml per 1Kcal intake

Micronutrients– Adjust according serum level (Na, K, Zn, PO4)

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Aims

• To improve nutritional status and prevent complications of malnutrition

• To maintain good hydration status• To avoid feeding complications e/\.g. re-

feeding syndrome, PNALD, electrolyte imbalance etc…

• To achieve normal biochemistry parameters

• To promote wound healing

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Average increase in energy intake and protein intake among the each patient

Energy Intake Changes

0

200

400

600

800

1000

1200

1400

1600

1800

Pre Energy

Post Energy

Protein Intake Change

0

10

20

30

40

50

60

70

80

Pre Prot

Post Prot

735 kcal increase 38g increase

kcal gm

PPN+oral supplement PPN+oral supplement

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Pharmaceutical Nutrients• Glutamine (EPUAP 2009)

– healing may be its function as a fuel & source for fibroblasts and epithelial cells needed for healing.

– Safe maximum dose for glutamine 0.57g/Kg/BW– Supplemental glutamine has not been shown to improve wound

healing and more studies are needed

• Arginine (EPUAP 2009)– stimulates insulin secretion promotes the transport of amino

acids into tissue cells and supports the formation of protein in the cells

– Maximum safe dosages of arginine have not been established– Avoid using Arginine suppl. in sepsis patient– Not available in PN due to stability

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Nutrition Monitoring

• Energy and nutrients requirements• PN Blood

– Serum Cholesterol & TG level, RFT, LFT– Serum Zn, Ca, Pre-albumin, Mg level

• Anthropometric data– BW, Triceps skin fold, Bio-impedance (BIA)

• Fluid requirement (IV and oral)– Weight change, edema, serum Na, and Osmolarity

• Oral intake• Infusion rate & duration? (common problem)• A multidiscipline approach (Nutrition Support Team)

showed promising benefit to patients

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Results

• 11 patients were retreived; 3 male and 8 female

• Average age: 79.9+/-7.8• Mean Alb significantly increased from 25

to 29.9 mmol/l (p=0.022).• Mean CRP were decreased significantly

from 126.3-39.5mg/l (p=0.017).• Zero mortality during study period

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Average reduction of pressure sore size

Change in Mean Wound Size

40

45

50

55

60

65

70

Pre Wound Size

Post Wound Size

• The mean wound surface area of all these patients

• significantly improvedfrom 64.16cm2 -52.74cm2 after the Nutrition intervention.

(n=11, p=0.032)

11.4cm square decrease in size of pressure sore

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Nutrition Related Complications

• PNALD (Parenteral Nutrition Associated Liver Diseases) – Elevated direct bilirubin concentrations (>2mg/dl, ~>33ummol), and in

some cases progressing to hepatic failure– Studies show omega 3 based formula prevent development of PNALD

Paed SBD• Refeeding Syndrome

– Too aggressive nutrition therapy (full strength on the 1st day)– Hypo PO4, K, Mg,

• Overfeeding– Hyperglycemia– High TG– Increase CO2 production– Fluid overload (PPN vs. CPN)ACD2010

Nutrition Related Complications• Hyperglycemia

• Adjust dextrose• Insulin therapy (added to PN)

• Hypoglycemia• Abrupt stopping of PN• aggressive taper down

• Electrolyte imbalance (Na, K, PO4)• Azotemia (renal impairment)• Mechanical

– phlebitis (K & Hypertonic solution)• – catheter occlusion• Calcium-phosphate precipitate (reported 2 deaths)

• Lower pH (add L-cysteine & hydrochloride) and increase amino acids content to lower the risk

• Use Calcium gluconate and Organic PhosphateACD2010

Our Role now!

• Use 1)EN, 2)TF, 3)PN+TF or PN+ EN to treat wound patients that fulfill our inclusion criteria

• Prescribe PN according to overseas protocol (not just for wound)

• Order lab tests (serum Zn, Lipid profile, RFT, LFT, etc…)

• Monitoring and adjust nutrients (PO4, Na, K…according to lab resultsACD2010

Some Observations

• Patients increase desire to eat during and after Dual route feeding

• Nutrients Recommended level for wound patients may not be adequate enough for some sever pressure ulcer patients

• A win-win-win situation (all parties are happy)

• Decrease use of antibiotic and wound careACD2010

The lady ,before

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After debridment,before PPN

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During PPN

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Case 1Diagnosis Multiple Sores: sacral, bilateral trochanteric & bilateral

ischial

Medical History Spinal melanoma with paraparesis in 11/2005, T11 recurrent tumor with excision done in 11/2007 and tomothearpy from HKSH ompleted in 1/20085/2008 operation with transection from T5 downward as intraop found multiple deposit from T6 downwardBecame Tetraplegic since 1/2009MRI brain & spine: multiple metastasis in cervical and dural metastases up to the cerebrum

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2009.06.09

2009.07.30,

2009.08.10Performed OT,See wound on

2009.08.21

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2009.09.07,

Patient discharged on 2009.10.13

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Case 2Diagnosis Suicide by Charcoal burning on 16/09/2009

Right calf compartment syndromeAcute kidney injury secondary to rhabdomyolysis and Compartment syndrome

Medical History Past history goodToxic effect of carbon monoxideHyperkalaemiaAcute Renal Failure with multiple heamodialysis performed

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Case 3Diagnosis RTA with spinal cord injury at T9

Respiratory failure on temporary trachostomyNecrotic bedsore: sacral region

Medical History SoliosisTB spine

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2009.09.29 2009.10.13 2009.10.16

2009.10.302009.10.20

Discharged to TPH on 2009.11.02ACD2010

Case 4Diagnosis Right lower limb acute arterial occlusion,

rhabdomyolysis, septic shock & ARDSARF with multiple HDMelaena with OGD: DU

Medical History IVDA on MethadonePTB, completed TreatmentAlcoholic liver diseaseCBD srticture

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2009.08.202009.09.21

Started NPWT on 2009.09.17

2009.11.09Revision of stump and VAC

applied in OT on 2009.00.06

2009.11.13 2009.11.18 2009.12.03Wound sutured

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80 year-old GentlemanMultiple Wounds

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After 23 Days Dual Route feeding

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Est. Costing

• PPN ~ $200-250/d (assume 1 bag/d)• Additives ~$110/d (all three)• Dipeptiven $250/bottle• Hospital diet ~$20-25/d• Enteral nutrition ~$5-25/packEst. total nutrition cost from $585 – 660/d(R/T feeding ~$20 – 100/d)ACD2010

Protocol ?• Assess the patient nutritional status by nurses,

dietitian, geriatrician.• Assessment of weight • Revise the dietary restriction if any• Consider nutritional support in term • Regular reevaluation by check arthoprometric

and biochemical parameters. (every 5-7 days)• Assessment the rehabilitation statusACD2010

Limitations……

• No control group of patients• Not a well designed study• Number of patients in the study is small• Albumin is not the best nutritional marker• Many confounders such as wound infection, co-

morbidities, different treatments,• Need better wound size measurement• Need a local clinical protocol ACD2010

Summary• Always use the gut first• Dual Route provide the extra nutrition requirements due

to acute disease effects that oral intake and/or Enteralnutrition failed to achieve

• Some chronic pressures ulcer does improve after the usage of Dual Route feeding plus traditional methods.

• Studies show proper parental nutrition support may:– Shorten LOS– Reduce infection rate – Reduced mortality rate– Reduce drugs and intervention cost

• Planning a well controlled study for wound and Dual feeding

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Thank you!

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