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Skin, Wounds and Nutrition Part 4

Skin, Wounds and Nutrition Part 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

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Skin, Wounds and Nutrition Part 4

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  1. Skin, Wounds and NutritionPart 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 20037Phone: (202) 521-6789 Fax: (202) 833-3636E-mail:npuap@npuap.org

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