1. By: Jessica Steinmetz Pressure Ulcers and Nutritional Supplements: Recommendations for Use

2. What are Pressure Ulcers? Areas of necrosis and ulceration Occur when tissues are compressed between a bony prominence and a hard surface Etiology: Pressure Friction Shearing forces Can result from pressure alone or combination

3. Risk Factors for Pressure Ulcers Old age Reduced subcutaneous fat Decreased capillary flow Immobility Co-morbidities Impaired circulation Immobilization Poor nutrition status Dehydration Diabetes Cardiovascular disease Incontinence PUs can develop in as little as 3 to 4 hours Immobilized trauma patients Worsen when skin is overly moist and macerated Perspiration Incontinence [1]

4. Clinical Assessment – Predicting Risk Braden Scale The patient is evaluated in 6 categories: Sensory perception Moisture Activity Mobility Nutrition Friction and shear Pressure sore risk increases as the score decreases: 15–16 = mild risk 12–14 = moderate risk < 12 = serious risk

5. Wound Staging Normal Tissue Intact skin, redness localized usually over bony prominence May be painful, firm, soft, warm or cool. [3]

6. Wound Staging (cont.) Partial thickness and loss of dermis Shallow open ulcer with red pink wound bed Intact or open/ruptured blister [3] Full thickness tissue loss Subcutaneous fat may be visible Slough may be present [3]

7. Wound Staging (cont.) Full thickness tissue loss Exposed bone, tendon or muscle Slough or eschar may be present [3] Full thickness tissue loss Base of ulcer cover in slough and/or eschar [3]

8. Treatment for Pressure Ulcers Reduce pressure! Direct care of ulcer Management of pain, infection, undernutrition Sometimes adjunctive therapy or surgery Treatment requires multiple simultaneous elements. [10]

9. Supplemental Nutrition Intervention: Macronutrients Calories. Energy. Carbohydrates. Protein.

10. Calories/Energy Essential for pressure ulcer healing Promotes anabolism Nitrogen and collagen synthesis, healing Increased kcals needed for hypermetabolism [4] Carbohydrates: Glucose is the main fuel source for collagen synthesis [4] Calorie needs: 30 - 35 kcal/kg body weight/day. 35 - 40 kcal/kg body weight/day Patients who are underweight or losing weight. [5]

11. Protein Role in wound healing: Synthesis of ulcer-healing enzymes Cell multiplication Collagen and connective tissue synthesis Promote positive nitrogen balance Recommendations: 1.2-1.5 g/kg Limitations: Protein levels as high as 2.0 g/kg may not increase synthesis May contribute to dehydration in elderly [4]

12. Supplements, Recommendations for Use Arginine. Glutamine. Vitamins A, E, C. Zinc. Whey protein.

13. Arginine Function: Stimulates insulin Promotes transport of amino acids into tissue cells Supports formation of protein [4] Normally produced in adequate amounts in the body Stress, illness may increase amounts needed [14] Recommendation for use: A 30-day trial period is suggested Adequate kcal and protein intake must be first priority. [14] Maximum safe dosage not established. Additional research needed [4]

14. Arginine Supplement Examples Arigment AT Advanced therapy for chronic wounds Argiment Advanced therapy for staged wounds ArginTein Nutrition support for Stage I and II pressure ulcers Ensure, Boost, Slim-Fast or Carnation Instant Breakfasts have been known to be used if Arginine supplements are not available [14]

15. Glutamine Supplementation Function: Most abundant amino acid in the body Fuel source for fibroblasts and epithlial cells Injury, surgery, infection and prolonged stress can lower gluatmine levels In these cases, supplementation may be helpful Crucial role in stimulating the inflammatory immune response occurring early in wound healing Recommendation for use: Typically available in 500 mg tablets Available by itself or as part of a protein supplement Powder, capsule, tablet, liquid Safe maximum dose is 0.57 g/kg

16. Glutamine Supplementation (cont.) Efficacy debated: One study shows oral Glu supplementation to improve wound breaking strength, increase mature collagen [16] Others show supplemental Glu to not improve wound healing Additional research also needed [4] Resource Glutasolve 15g L-Glutamine Restore-X packets 10g Glutamine Impact Recover 5g L-Glutamine Dietary sources: Beef, pork, poultry Milk, yogurt, ricotta cheese, cottage cheese Raw spinach, raw parsley, and cabbage

17. Vitamin Supplementation Vitamin A: Deficiency results in: Impaired wound healing Alteration in immune function, may increase likelihood of wound infections Supplementation is typically not strongly justified [12] Potentially toxic Vitamin E: Anti-oxidant, anti- inflammatory properties Effect in healing acute/chronic wounds is controversial Further research is needed in humans [11]

18. Vitamin Supplementation (cont.) Vitamin C: Deficiency associated with delayed wound healing Supplementation enhances wound healing The Agency for Health Care Research and Quality recommends: Stage I and II – 100mg - 200mg per day Stage III and IV - 1,000mg - 2,000mg per day [12] ADA Evidence Analysis Library rates the previous Vitamin recommendation as Conditional

19. Zinc Supplementation Function: Cellular metabolism Protein synthesis Maintains integrity of skin and mucosal membranes [8] Supplemental forms: Zinc gluconate Zinc sulfate Zinc acetate Percentage of elemental zinc varies by form [8] Supplementation: ZnSo4 220mg (50mg elemental Zinc) 2x/day recommended as a standard oral replacement [12] May be effective for treating leg ulcers in patients with low serum levels [8] No evidence that general use in patients with chronic leg ulcers is effective [8]

20. Zinc Supplementation (cont.) High-dose supplements may be limited to 2-3 weeks May adversely affect: Copper status Immune response Lipid profiles GI side effects Important to minimize risk of adverse effects unless justified by ongoing losses

21. Whey Supplementation Whey definition: Dairy product containing milk serum proteins Function: May increases glutathione synthesis and cellular antioxidant defense Glutathione = combination of cysteine, glycine and glutamine Efficacy: Long-term effects of whey for wound healing unknown Needs further research [13]

22. Whey Supplement Example ProNutra High risk patients susceptible to: Muscle wasting, stage I & II pressure ulcers, PEM, protein malabsorption, or compromised immune systems: 1 serving (1 bottle) per day is recommended. Stage III & IV pressure ulcers or patients with severe PEM: 2 servings (2 bottles) per day are recommended. For long term maintenance 1 serving (1 bottle) 2 or 3 times per week ProNutra may be added to oral and tube-administered enteral products. [9]

23. Nutrition/ Supplemental Goals

24. Identifying PEM Assessing malnutrition is important for determining the use of supplements Markers for identifying PEM in patients with pressure ulcers Unintentional weight loss of ≥ 5% in the previous 30 days or of ≥10 % in the previous 180 days Weight >80% of ideal Serum albumin level <3.5 g per dL (35 g per L)* Prealbumin level <15 mg per dL (150 mg per L)* Transferrin level <200 mg per dL (2 g per L) Total lymphocyte count <1,500 per mm3 (1.50 × 109 per L) [7]

25. Nutrition Goals for Prevention of PU’s Making a plan to improve nutritional status/preventing pressure ulcers 1. Identify and correct factors compromising protein/ calorie intake 2. Consider supplements/support for nutritionally those compromised patients. 3. Offer and encourage hydration 4. MVI with minerals per physician’s order or recommend when necessary. [11]

26. Conclusion Adequate nutrition and a basic MVI are typically the first line of defense Calorie and protein intakes need to be adequate for supplementation to be effective There is no research to justify administration of vitamin/mineral supplements that are above the US RDI [4] Additional research is needed for the definitive justification for the continual use of supplements in wound healing

27. Resources 1. Pressure Ulcers. Merek Manual. Accessed July 10, 2012 http://www.merckmanuals.com/professional/dermatologic_disorders/pressure_ulcers/pressure_ulcers.html?qt=pressure ulcers&alt=sh 2. NPUAP Free Resource Category/Staging Illustrations: http://www.npuap.org/resources.htmhttp://www.npuap.org/resources.htm 3. Image Reference : http://www.npuap.org/pr2.htm Image Reference : http://www.npuap.org/pr2.htm 4. Dorner B, Posthauer ME, Thomas D. The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper.2009 NPUAP Nutrition White Paper 1. National Pressure Ulcer Advisory Panel http://www.npuap.org/Nutrition%20White%20Paper%20Website%20Version.pdf 5. What is the Current Recommendation for Vitamin and Mineral Supplementation for Pressure Ulcers. Academy of Nutrition and Dietetics.2008. Accessed July 10, 2012. http://www.eatright.org/Public/content.aspx?id=5825&terms=pressure+ulcershttp://www.eatright.org/Public/content.aspx?id=5825&terms=pressure+ulcers 6. Heyman H, Van De Looverbosch DE, Meijer EP, Schols JM. Benefits of an oral nutritional supplement on pressure ulcer healing in long-term care residents. J Wound Care 2008 Nov;17(11):476-8, 480. Source: OCMW Nursing Homes, Antwerp, Belgium. http://www.ncbi.nlm.nih.gov/pubmed/18978686. 7. Bluestein D, Javaheri A. Pressure Ulcers: Prevention, Evaluation, and Management. Am Fam Physician. 2008 Nov 15;78(10):1186- 1194. Accessed July 10, 2012. http://www.aafp.org/afp/2008/1115/p1186.htmlhttp://www.aafp.org/afp/2008/1115/p1186.html 8. Office of Dietary Supplements. Zinc. National Institute of Health. Accessed July 11, 2012. http://ods.od.nih.gov/FactSheets/Zinc/http://ods.od.nih.gov/FactSheets/Zinc/ 9. Pronutra. Drugs.com. Accessed July 11, 2012. http://www.drugs.com/drp/pronutra-protein-supplement.htmlhttp://www.drugs.com/drp/pronutra-protein-supplement.html 10. Image Reference: Wounds International, Accessed July 12, 2012 http://cms2.selesti.com/media/PUAP-poster.gifhttp://cms2.selesti.com/media/PUAP-poster.gif 11. Pressure Ulcer Prevention Points. National Pressure Ulcer Advisory Panel. 2007. Accessed July 12, 2012. http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-prevention-points/

28. Resources 12. Recommendations Summary, Spinal Cord Injury Assessment of Nutritional Needs for Pressure Ulcer Academy of Nutrition and Dietetics. Evidence Analysis Library. Accessed July 12, 2012 http://www.adaevidencelibrary.com/template.cfm?template=guide_summary&key=2378&auth=1 http://www.adaevidencelibrary.com/template.cfm?template=guide_summary&key=2378&auth=1 13.Velioglu Ogünç A13.Velioglu Ogünç A, Manukyan M, Cingi A, Eksioglu-Demiralp E, Ozdemir Aktan A, Süha Yalçin A. Dietary whey supplementation in experimental models of wound healing. Int J Vitam Nutr Res. 2008 Mar;78(2):70-3. Accessed July 13, 2012. http://www.ncbi.nlm.nih.gov/pubmed/18791975Manukyan MCingi AEksioglu-Demiralp EOzdemir Aktan ASüha Yalçin AInt J Vitam Nutr Res. http://www.ncbi.nlm.nih.gov/pubmed/18791975 14.Grieger L. Nutrition and Wound Care. Today’s Dietitian. Vol. 11 No. 8 P. 12 August 2009 Issue Accessed July 15, 2012. http://www.todaysdietitian.com/newarchives/072709p12.shtml. http://www.todaysdietitian.com/newarchives/072709p12.shtml 15. Glutamine. University of Marlyand Medical Center. Accessed July 15 2012. http://www.umm.edu/altmed/articles/glutamine- 000307.htm#ixzz20hU84Phxhttp://www.umm.edu/altmed/articles/glutamine- 000307.htm#ixzz20hU84Phx 16. Guo S. Di Pietro L.A. Factors Affecting Wound Healing J Dent Res. 2010 March; 89(3): 219–229.