Skin, Wounds and NutritionPart 4

Assessing Nutritional Needs

Energy or calorie requirements Protein requirements Micronutrient requirements

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

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

Micronutrient Requirements Increased need for cellular function and

formation

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

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

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

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

Basic Principles--Fat 20-25% of the diet No more than 2 grams/kg/day Need to monitor triglycerides

keep triglycerides < 250 mg/dL

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

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

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

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

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

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

Basic Principles--Micronutrient Support Vitamin E

Responsible for collagen synthesis Assists in wound healing DOES NOT prevent scar formation

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

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

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

Basic Principles--Micronutrient Support Copper

Cofactor for connective tissue production Collagen polymerization Formation of cross linkages to enhance scar

strength Erythrocyte formation

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

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

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

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

Basic Principles--Micronutrient Support Glutamine

Precursor for purines and pyrimidines Fuels fibroblasts Anti-catabolic, anabolic properties Preserves LBM Stimulates release of Human Growth

Hormone

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

Basic Principles--Micronutrient Support Dietary Nucleotides

Building blocks for DNA/RNA Improve immune function Assist in wound healing Found in any animal protein

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

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

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

Intervention Strategies Pharmacologic strategies

Appetite stimulants Megace

Metabolic nutrients Glutamine Arginine HMB

Anabolic agents Somatotropin—(can be very expensive) Oxandrolone

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!!!!

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

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

Directives

AHCPRThe Agency for Health Care Policy and

ResearchP.O. Box 8547Silver Spring MD 20907

1-800-358-9295 (9 am to 5 pm ET)http://www.ahrq.gov/clinic/cpgonline.htm

NPUAPThe National Pressure Ulcer Advisory Panel

1255 Twenty-Third Street NW, Suite 200, Washington, DC 20037Phone: (202) 521-6789 Fax: (202) 833-3636

E-mail: npuap@npuap.org