1. Nutrition Guidelines for Pressure Ulcer Management 1/4/07

2. Braden > 18 No Pressure Ulcer or Non-Healing Wound Monitor intake and weight Consult dietitian if: Usual criteria on Admission Database Intake consistently less than 75% Nausea, vomiting, diarrhea Metabolically stressed state - trauma, fever Significant weight loss (non fluid related): 1% in 1 week 5% in 1 month 7.5% in 3 months 10% in 6 months

3. Recommended RD Actions Braden > 18 without Pressure Ulcer with ↓appetite, weight loss,  needs,  loss via V & D Complete nutrition assessment Based on findings: Request pre-albumin Add oral supplements Add between meal snacks Assistance, reminders, encouragement at mealtime 3 Day Calorie Count Based on response to above consider: Tube feeding Parenteral nutrition

4. Braden < 18 Without Pressure Ulcer/Non Healing Wound With adequate nutrition intake Nutrition Goals: Maintain current intake of nutrition Achieve and maintain desirable weight Routine Follow Up: Visual assessment of skin Back of head Elbows Heals Back side Assessment of: Weight Intake Pre-albumin Changes in condition

5. Braden < 18 Without pressure ulcer or non healing wound; With inadequate hydration, protein &/or weight loss Nutrition Goal: Protein: 1.2g pro/kg/d Calories: 25 – 30 kcals/kg/d 29 – 33 kcals/kg/d Para 24 – 27 kcals/kg/d Quad Use ABW subtract 5 – 10 kcals/kg/d for Obesity Fluid: 30 ml/kg; min of 1500 ml/d unless contraindicated SCI: 35 ml/kg; min 2500 ml/d unless contraindicated Add 10 – 15 ml/kg for air fluidized beds

6. Recommended RD Actions Continued Braden < 18 Without pressure ulcer or non healing wound; With inadequate hydration, protein &/or weight loss Complete nutrition assessment First meet fluid needs Supplement with whey protein powder or use whey based tube feeding e.g.Propass 6 gm/pkt If BMI < 20 change diet to high cal/high protein Add therapeutic multi-vit/min supplement

7. Recommended RD Actions Cont Braden < 18 Without pressure ulcer or non healing wound; With inadequate hydration, protein &/or weight loss Follow up weekly: Visual assessment Assessment of wt, intake, pre-albumin, medical condition Correct source of poor intake if able Food preferences Constipation Illness depression Pain Medication causing poor appetite Consider glutamine: 10 g/d Evaluate need for anabolic agent and/or nutrition support

8. Stage 1 & 2 Pressure Ulcers Without: heavy exudate, VAC therapy, poor appetite, diarrhea, weight loss, Alb < 3.5 or PAB < 15 Nutrition Goal: Protein:1.2 – 1.5g pro/kg/d Calories: 25 – 30 kcal/kg/d 29 - 33 kcals/kg/d Para 24 - 27 kcals/kg/d Quad Use ABW & subtract 5-10 kcals/kg/d for obese Fluid: 30 ml/kg; min of 1500 ml/d unless contraindicated SCI: 35 ml/kg; min 2500 ml/d unless contraindicated Add 10 – 15 ml/kg for air fluidized beds (Matrix Matress Replacement or Kinair)

9. Recommended RD Actions: Stage 1 & 2 Pressure Ulcers: Without: H eavy exudate, VAC therapy, poor appetite, diarrhea, wt loss, Alb < 3.5 or PAB < 15 Complete nutrition assessment First meet fluid needs 10 – 15 gm/d whey protein 7 – 15 gm/d arginine Therapeutic multi vitamin min supplement 25 mg zinc along with 2 mg of Cu for 2 weeks or less Follow up weekly

10. Stage 1 & 2 Pressure Ulcers With: heavy exudate, VAC therapy, poor appetite, diarrhea, weight loss, Alb < 3.5 and/or PAB < 15 Nutrition Goal: Protein:1.5 – 2.5 gm pro/kg/d Calories:30 – 35 kcal/kg/d 33 - 35 kcals/kg/d Para 27 - 30 kcals/kg/d Quad Use ABW & subtract 5-10 kcals/kg/d for obese Fluid: 35 ml/kg; min of 2000 ml/d unless contraindicated SCI: 35 ml/kg; min 2500 ml/d unless contraindicated Add 10 – 15 ml/kg for air fluidized beds (Matrix Mattress or Kinair bed)

11. Recommended RD Actions: Stage 1 & 2 Pressure Ulcers With: heavy exudate, VAC therapy, poor appetite, diarrhea, weight loss, Alb < 3.5 and/or PAB < 15 Complete Nutrition Assessment First meet fluid needs 10 – 15 gm/d whey protein 10 – 20 gm/d arginine Therapeutic multi vitamin min supplement 25 mg zinc along with 2 mg of Cu daily for 4-6 weeks or less Check Oxandrolone guidelines for appropriateness if weight loss and skin breakdown present (See Oxandrolone guidelines) If Tube Fed, use peptide based formula; avoid formulas high in simple CHO Follow up at moderate to high risk (1-2 times/wk)

12. Stage 3 & 4 Pressure Ulcer Non Healing Wound Nutrition Goal Protein:1.5 – 2.0 gm/pro/kg/d Calories:30 - 35 kcals/kg/d (35 – 40 if heavy exudate) 33-35 kcals/kg/d para 27 – 30 kcals/kg/d quad Fluid: 35 ml/kg; min of 2000 ml/day unless contraindicated SCI: 35-40 ml/kg ; min 2500-3000 ml/d unless contraindicated Add 10 – 15 ml/kg for air fluidized beds (Matrix Mattress or Kinair bed apply)

13. Recommended RD Actions: Stage 3 & 4 Pressure Ulcer/Non Healing Wound Complete Nutrition Assessment First meet fluid needs 10 – 15 gm/d whey protein 10 – 20 gm/d arginine Therapeutic multi vitamin min supplement 25 mg zinc along with 2 mg of Cu daily for 4-6 weeks Check Oxandrolone guidelines for appropriateness if weight loss and skin breakdown present (See Oxandrolone guidelines) If Tube Fed, use peptide based formula; with MCTs; avoid formulas high in simple CHO RD follow at moderate to high risk (1- 3 times/wk)

14. Oxandrolone Action: amino acids driven into protein synthesis pathway; catabolic activity is decreased Actions/Benefits Relative low cost Anti catabolic Increased protein synthesis Marked return of lean mass in conjunction with optimum nutrition vs nutrition alone Wt gain approximately 75% lean body tissue Acts on cell androgenic receptors Cleared by kidneys, avoiding hepatotoxicity Anabolic effect is dose dependent Well tolerated for long- term use Contraindications/Side Effects Stimulation of androgen- sensitive tumors, mainly prostate CA Known liver disease or LFTs greater than twice the upper limit of normal Oral anticoagulation therapy e.g. warfarin Pregnancy Breast Cancer (male or female; hypercalcemic type) Prostate CA Nephrosis Hypocalcemia Uncontrolled diabetes

15. Dosing of Oxandrolone Usual Dose: 10 mg twice daily Renal insufficiency: 5 mg twice daily Strive for adequate protein intake first

16. Conditionally Essential Amino Acids Arginine: Wound Healing (via IGF 1) Required for collagen synthesis (precursor to polyamines) Increased in collagen deposition in wound bed with 15g of arg/d Average dietary intake 7.5g arg/day Increased blood flow Nitric Oxide Pathway NO levels decreased in DM Glutamine: Nitrogen Shuttle Regulates protein turnover Stores depleted at 10 – 15% loss of lean body mass Immunity Preferred fuel source for lymphocytes & enterocytes N-Acetyl Cysteine + Glutamine = Glutathione which leads to decreased oxidative stress GI Function & Immunity Restores gut integrity & brush boarder which improves absorption & appetite (20 g gln/d) Precursor for nucleotides Helps maintain Acid base balance Ammonia production

17. Conclusions: These recommendations are from best practice organizations and the dietetics profession. Several have not been tried here at HCMC and are worthy of trial. Our challenge is to implement these guidelines and evaluate effectiveness in the population at HCMC.