1. Skin, Wounds and Nutrition Part 4

2. Assessing Nutritional Needs Energy or calorie requirements Protein requirements Micronutrient requirements

3. Energy Requirements May be up to 50% more calories than the non-stressed individual Calculate using Harris Benedict formula, Mifflin St Jeor, or indirect calorimetry

4. Protein Requirement Increased relative to increased demands for protein synthesis and increased losses of amino acids Needs Stage 1-- 1.0 gram/kg Stage 2--1-1.2 grams/kg Stage 3--1.25-1.5 grams/kg Stage 4--1.5-2.0 grams/kg Note: Protein above 1.5 gm/kg may not help protein syntheses and may cause dehydration, particularly in the elderly or those with impaired renal function

5. Micronutrient Requirements Increased need for cellular function and formation

6. Interventions to Promote Healing Provide optimum nutrition early adequate energy and nutrient profile adequate protein necessary micronutrients Use anabolic agents, if necessary Provide exercise stimulus to muscles, to increase anabolism

7. Basic Principles--CHO 55-60% of diet Provide as complex CHO glucose is the prime energy source for the cell Leukocytes apparently use glucose to promote phagocytic activity of lymphocytes prior to fibroplasia Maximum tolerated is 7-8 grams/kg/d for respiratory patients Give insulin for glucose >250 mg/dL and decrease intake if severe hyperglycemia

8. Basic Principles--Protein 20-25% of diet from protein Increased protein intake decreases the net nitrogen losses by increasing the amino acid flow into the protein synthesis channel Essential for protein synthesis and new cell growth Protein is the component of collagen and other structural components

9. Basic Principles--Protein Will need increased fluids Higher risk for dehydration BUN will probably increase NOTE: Excessive protein does NOT encourage faster healing as the body does not store protein but turn it into sugars

10. Basic Principles--Fat 20-25% of the diet No more than 2 grams/kg/day Need to monitor triglycerides keep triglycerides < 250 mg/dL

11. Fatty Acids/Omega 3 Synthesize prostanoids Normal cell membrane function Essential Fatty Acid Deficiency (EFAD) impairs wound healing Often overlooked by RD Can obtain in foods and oils salmon, mackerel, albacore tuna, sardines, flax canola and soybean oil

12. Basic Principles-- Micronutrient Support Vitamin A Normal inflammatory response Allows epithelization, collagen synthesis, and collagen cross-linking Maintains normal humoral defense mechanism Seems to limit complications Need a good source (DAILY) in wound healing

13. Basic Principles-- Micronutrient Support Vitamin A Supplements given: to counteract catabolic effects of glucocorticoids to corticosteroid dependent patients to promote healing to those with poor nutrient stores or malabsorption Note: Too much may exacerbate inflammatory response

14. Basic Principles-- Micronutrient Support Vitamin C works with Amino Acids proline and lysine during collagen synthesis needed for carnitine production for fatty acid metabolism Reduces risk of wound reopening Body does not store vitamin C

15. Basic Principles-- Micronutrient Support Vitamin C deficiency--Scurvy Symptoms may develop rapidly but reverse quickly with treatment Interferes with fibroblast function Alters healing process of collagen synthesis No secretion of procollagen chains Impaired polymerization Wrong amino acid sequence Increased blood cell fragility

16. Basic Principles-- Micronutrient Support Thiamine necessary for oxidation, reduction reactions helps form lysyl oxidase to strengthen collagen necessary for adequate collagen formation Vitamin K Responsible for normal coagulation of blood Prolonged bleeding times and hematoma formation may hinder wound healing

17. Basic Principles-- Micronutrient Support Vitamin E Responsible for collagen synthesis Assists in wound healing DOES NOT prevent scar formation

18. Basic Principles-- Micronutrient Support Zinc Role in cellular proliferation and protein synthesis Excess zinc may interfere with wound healing via affecting lysyl oxidase, an enzyme involved in collagen synthesis Excess interferes with copper and iron absorption and metabolism

19. Basic Principles-- Micronutrient Support Zinc--cont. Needed for ALL enzymatic reactions Urinary losses increase with stress and weight loss Body stores are often depleted in patients with malnutrition, chronic diarrhea and chronic corticosteroid use

20. Basic Principles-- Micronutrient Support Zinc cont. In deficiency state, may find low rate of epithelialization Deficiency causes decreased wound and collagen strength Supplementation often done in wound management but no evidenced based studies to prove its need

21. Basic Principles-- Micronutrient Support Copper Cofactor for connective tissue production Collagen polymerization Formation of cross linkages to enhance scar strength Erythrocyte formation

22. Basic Principles-- Micronutrient Support Magnesium Necessary for all phases of wound healing Translation and synthesis of peptide chains Depletion may occur in patients with chronic diarrhea, fistulas, SBS Calcium A cofactor for some collagenases during remodeling Necessary for normal blood coagulation

23. Basic Principles-- Micronutrient Support Iron Enhances enzymatic activity of prolyl hydroxylase during hydroxylation of proline and lysine Iron stores in the elderly are at their highest Make sure check true anemia not anemia of chronic disease

24. Basic Principles-- Micronutrient Support Arginine Stimulates collagen synthesis Enhances cellular immune mechanisms, especially T-cell function Assists cell growth and replication Helps promote wound healing Obligatory precursor for wound protein synthesis

25. Basic Principles-- Micronutrient Support Arginine--cont. Made in the kidney May be consumed in diet Breakdown of body protein Can be found in enteral formulas with immune-enhancing nutrients

26. Basic Principles-- Micronutrient Support Glutamine Precursor for purines and pyrimidines Fuels fibroblasts Anti-catabolic, anabolic properties Preserves LBM Stimulates release of Human Growth Hormone

27. Basic Principles-- Micronutrient Support Glutamine--cont Levels drop dramatically during stress Found in abundance normally Enteral formulas or modular forms available 10-20 grams daily for supplement

28. Basic Principles-- Micronutrient Support Dietary Nucleotides Building blocks for DNA/RNA Improve immune function Assist in wound healing Found in any animal protein

29. Basic Principles--Water 30 ml per kg body weight unless contraindicated 1 mL/cal for enteral tube feeding Additional 10-15 mL/kg/day when air fluidized beds are used Additional for elevated temperatures

30. Basic Principles--Water Participates in most metabolic reactions Acts as a solvent for minerals, vitamins, amino acids, glucose, and other small molecules enabling them to diffuse in and out of cells Transports vital materials to cells and waste away from cells

31. Intervention Strategies Nonpharmacologic strategies Counseling and education Patients should be told about and become involved in decisions as should the families Optimizing food intake Start with foods rather than supplements Calorie enhanced/protein enhance Supplements Immune enhanced formulas 2 Kcal Med pass

32. Intervention Strategies Pharmacologic strategies Appetite stimulants Megace Metabolic nutrients Glutamine Arginine HMB Anabolic agents Somatotropin—(can be very expensive) Oxandrolone

33. Calorie Needs in Wound Healing 30 kcal/kg body weight generally accepted >30 kcal/kg should promote positive nitrogen balance Use indirect calorimetry if available and if accuracy is critical Liberalize diet!!!!

34. Vitamin & Minerals Implicated in wound healing Remember, they do not hasten healing once normal stores are present No question that information is conflicting and confusing but with a litigation culture, we have become a supplement oriented society

35. Indication for Nutrition Support May facilitate wound healing Ability to optimize nutrient intake Must be monitored Must be in accordance with Advanced Directives

36. AHCPR The Agency for Health Care Policy and Research P.O. Box 8547 Silver Spring MD 20907 1-800-358-9295 (9 am to 5 pm ET) http://www.ahrq.gov/clinic/cpgonline.htm

37. NPUAP The National Pressure Ulcer Advisory Panel 1255 Twenty-Third Street NW, Suite 200, Washington, DC 20037 Phone: (202) 521-6789 Fax: (202) 833-3636 E-mail: npuap@npuap.org npuap@npuap.org