Wound Healing Outline, Study notes of Nutrition

Download Wound Healing Outline and more Study notes Nutrition in PDF only on Docsity! 1 Wound Healing Clinical Nutrition Support Service Hospital of the University of Pennsylvania Jung Kim, RD CNSD, LDN Tricia Stefankiewicz, MA, RD, CNSC, LDN Outline • Wounds and nutrition refresher • UPHS evidence-based guideline for nutrition support of patients with wounds Inflammation Injury x 4-6 days: Wound exudation and fibrin clot formation, neutrophils remove bacteria, macrophage activity Proliferation Normal Wound Healing Vitamin A 3-5 days post-injury x 2-3 weeks: Epithelialization, angiogenesis, fibroblast proliferation, collagen deposition and crosslinking, wound contraction Remodeling 2-3 weeks post-injury x 2 yrs: Collagen maturation and stabilization, development of tensile strength Thompson et al, NCP, 2005;20:331-347. Vitamin C Zinc 2 Nutritional Risk Factors for Development of Pressure Ulcers • Malnutrition related to – Poor appetite – Needs assistance with eating – Impaired sense of taste and smell – Inadequate intake of protein, energy, fluid, micronutrients • Weight loss Risk Factors for Impaired Wound Healing • Significant weight loss • Inadequate protein intake • Inadequate nutrient intake • Extreme body mass index (BMI) – low or high with limited mobility • Hypoalbuminemia – Dorner B et al. Adv Skin Wound Care. 2009;22:212-221. 5 Transport Proteins • Albumin, prealbumin – Albumin strong prognostic indicator in many populations di f l i k d– Pre ctor o pressure u cer r s vs. ue to pressure ulcer inflammation • Monitor trends – Albumin half-life almost 21 days – Prealbumin 3 days • Consider checking CRP to evaluate inflammation Fluid Function and Goals • Maintain skin turgor, perfusion, and oxygenation of healthy tissue • Dehydration: – Impairs oxygen delivery to wounded tissues – Risk factors for dehydration: • Fever, diarrhea, vomiting, diuresis, draining or open wounds, fistulae, air fluidized bed • Goal: 1 mL of fluid intake per kcal/day Role of Vitamins • Vitamin A – Deficiency impairs wound healing • Impaired collagen synthesis and cross-linking – Indication for supplementation: • Vitamin A deficiency • Glucocorticoid administration • Radiation or chemotherapy • Diabetes – Contraindications: • Renal or liver failure • Protein deficiency 6 Vitamin A Recommendations Stage I-II: • Replete only if deficient • 10, 000 – 25,000 IU x 10 days Stage III-IV: • 5000 IU per 1000 kcal • Concomitant glucocorticoid use: • 10,000-15,000 IU x 7 days Role of Vitamins • Vitamin C – Deficiency: impaired collagen cross-linking, reduced wound tensile strength, increased wound dehiscence Elderl at risk for deficienc– y y • Poor dietary intake and malnutrition decrease vitamin C level – Indication for supplementation: • Deficiency : difficult to determine , expensive to test – Baseline repletion dosage unclear – Higher doses for increased wound severity Vitamin C Recommendations • Stage I-II: – 250 mg/day • Stage III-IV: – 1000 mg/day (250 mg – 4x/day) • Vacuum Dressing: – 1000 mg/day (250 mg – 4x/day) • Renal Failure: 250 mg/day 7 Role of Minerals • Zinc – Deficiency: wound strength reduced, collagen synthesis decreased, slower rate of epithelialization, decreased immunity – Indications for supplementation: • Replete in deficient state - 220 mg/day – Risk Factors for deficiency: • Wound vac drainage, ostomy, diarrhea, malabsorption (can discontinue once drainage decreased) – Toxicity: • Impaired copper status (necessary for crosslinking) • Reduced wound healing Role of Amino Acids • Arginine – Conditionally essential amino acid – May influence microvascular perfusion  enhanced collagen production via proline synthesis • Stechmiller et al, NCP 2005;20:52-61 Stimulation of immune function– – Recent studies demonstrate ↓ wound area, ↓ exudate, more rapid wound closure • Small samples • Few randomized-controlled trials – Frias Soriano et al, J Wound Care 2004;13(8):319-22. – Heyman et al, J Wound Care 2008;17(11):476-8. Oral Supplement with Arginine Grade IV pressure ulcer - baseline, after 3 weeks, after 9 weeks Heyman H et al. J Wound Care 2008; 17 (11); 476-8 10 Oral Nutrition Supplements Nepro Magic Cup Mighty Shake No Sugar Added Mighty Shake Ensure Plus Glucerna Summary: Key Points • Provide adequate kcals/protein – Calorie counts? – May require combined therapies (specialized nutrition support + oral diet) – High calorie/high protein supplements • Correction of vitamin/mineral deficiencies • Adequate glycemic control • Optimize hydration • Consider amino acid supplements 1/27/08 (elt [ela lovg 11