Nutritional intake in community patients with pressure ulcers

Nutrition and cutaneous wound healing

Wound healing is a complex and energy-demanding process. The relationship between nutrition and wound healing has been recognized for many centuries. Several studies have indicated that nutritional deficiencies are more prevalent among patients with chronic wounds. Malnutrition may alter the inflammatory response, collagen synthesis, and wound tensile strength, all of which are crucial for wound healing. Although the specific role of nutrition and supplementation in wound care remains uncertain, it is necessary to identify and correct nutritional imbalances to avoid any potential deterioration of the healing process. It is also important to recognize the differences in pathophysiology between acute and chronic wounds. A burn, surgical, or a traumatic wound is different from a diabetic foot ulcer, which is different from a pressure ulcer. Chronic wounds are more prevalent in the aging population, and patients often have underlying comorbidities, such as diabetes mellitus, peripheral vascular disease, connective tissue disease, or other systemic illnesses that may alter energy metabolism and contribute to impaired healing. Management approaches to acute wound care may not apply universally to chronic wounds. In this review, we discuss the available data and possible roles for nutrition in wound healing.

Expanded Flaps in Surgical Treatment of Pressure Sores: Our Experience for 25 Years

BACKGROUND

Because the ischial region is the main weight-bearing area in sitting, it is one of the areas most frequently affected by pressure ulcers in paraplegic patients resuming the sitting position during the subacute and chronic stages. The techniques described to date have not been able to reduce the high rates of recurrence and flap dehiscence. Other groups have described successful tissue expansion in the treatment of pressure ulcers, but to date, the long-term results of the procedure have not been reported.

METHODS

The long-term follow-up of 138 reconstructions of the ischial region in patients with pressure ulcers types III to IV treated with posterior thigh expanded rotation flaps is reported.

RESULTS

All patients achieved complete resolution, with adequate coverage of deeper layers, although 15.94% presented minor complications. None of these complications impeded full repair of the lesion. The 28 lesions that recurred were all reconstructed with the re-expansion of the same flap. There were no cases of flap dehiscence.

CONCLUSIONS

The use of tissue expanders to treat ischial pressure ulcers, especially in patients with long life expectancy, offers important advantages over other approaches. The procedure provides abundant, high-quality tissue and may be repeated many times without creating new scars. With the use of tissue expanders, other reconstructive options can be reserved for the future.

The Topical Evolution: Free Ions, Orthomolecular Agents, Phytochemicals, and Insect-Produced Substances

Significance: A variety of topical antiseptic substances have been used historically to treat open wounds with suspected tissue infection or that are slow to heal. However, the effectiveness of these substances in treating infected or recalcitrant wounds remains controversial. Recent Advances: Newly formulated topical antiseptics delivered through differing dressing technologies, such as ionic substances, hold the potential to limit the development of and treat antibiotic-resistant microbes in open wounds. Other topically delivered substances, such as insect-derived substances, orthomolecular agents, and phytochemicals, also present opportunities to optimize wound healing by decreasing tissue bioburden and facilitating the wound healing process. Critical Issues: Limited systemic perfusion of open wounds in individuals with certain diagnoses, such as peripheral arterial disease or necrotizing infection and the increasing number of antibiotic-resistant wound pathogens, suggests a continued role for topically applied antiseptic agents. Likewise, the failure of wounds to heal when treated with standard of care therapy opens the door to innovative treatment approaches that include the natural substances described in this article. Future Directions: Evidence for the use of select topical antiseptic agents from each of the aforementioned categories will be discussed in this article. Additional well-controlled clinical studies are needed to provide definitive recommendations for many of these topical agents.

Nutrition and wound healing

Continued research and development in the field of wound healing holds the potential to affect both quality of life and incidence of mortality. For the health care provider to promote successful wound healing, an understanding of the function of nutrients in inflammation and tissue growth is helpful. The intent of this paper is to discuss the metabolic and cellular pathways crucial to wound healing and identify appropriate nutritional interventions and clinical applications.

Nutritional issues in older adults with wounds in a clinical setting

BACKGROUND

The ability for patients to access and consume sufficient quantities of nutrients to meet recommendations for wound management is vital if decline in nutritional status during hospital admission is to be prevented. This study aims to investigate menu quality, consumption patterns, and changes in nutritional status for inpatients with wounds.

METHODS

Wound healing recommendations were compared against the nutrient content of the inpatient menu. Individual intakes were compared to estimated requirements: energy using the Schofield equation; protein using wound healing recommendations; vitamin A, C, and zinc using the recommended daily intake (RDI).

RESULTS

The inpatient menu did not provide sufficient energy or zinc to meet the estimated average requirement while the ordering practices of participants allowed all RDI to be achieved except for zinc. Actual intake fell below recommendations: 62%, 41%, 55%, and 79% of patients not meeting energy, minimum protein requirements, vitamin A or zinc RDI respectively. A nonsignificant trend for weight loss, particularly fat mass, was observed over time.

CONCLUSION

Inpatients with wounds are at risk of being unable to consume sufficient quantities of nutrients important for healing and prevention of decline in nutritional status. This is despite the menu seemingly providing sufficient nutrients. More attention to education, encouragement, and supplementation are recommended.

Nutrition status and pressure ulcer: what we need for nutrition screening

BACKGROUND

Pressure ulcers (PU) and malnutrition exist in elderly hospitalized patients as a significant and costly problem. The aim of the study was to compare different screening tools to assess nutrition status and to verify them for usage in clinical routine.

METHODS

Nutrition status (body mass index [BMI], Mini Nutritional Assessment [MNA], weight loss) was determined in 484 (326 female/158 male) multimorbid elderly patients with mean age of 79.6 +/- 7.6 (80.9 +/- 7.4 female/76.9 +/- 7.4 male) years. Bioelectrical impedance analysis (BIA; Nutrigard 2,000-M) was used for evaluation of body composition. Activities of daily living (ADL) were measured with the Barthel Index. PUs were divided into stages I-IV (European Pressure Ulcer Advisory Panel [EPUAP]) and were assessed by the Norton scale.

RESULTS

The prevalence of PU was 16.7%, with a median Norton scale of 20 (range, 17-24). According to MNA, 39.5% of the PU patients were malnourished, and 2.5% were well nourished. By contrast, 16.6% of the non-PU patients were malnourished, and 23.6% were well nourished. BMI decreased significantly in PU patients (p < .008). BIA resulted in no significant resistance and reactance but in a significant reduction of phase angle in PU. According to a significantly reduced body cell mass and lean body mass in PU patients, the ADL decreased in these patients, too. Furthermore, we analyzed a significant effect of age, ADL, MNA, BMI, phase angle, and body cell mass on the Norton scale.

CONCLUSIONS

The MNA as a screening and assessment tool is easy to use to determine the nutrition status in multimorbid geriatric patients with PU. Further studies are needed to show an improved outcome of PU healing if evaluation of nutrition status is part of routine clinical practice in multimorbid elderly risk patients within the first day after admission.

Evaluation of the dissemination and implementation of a nutritional guideline for pressure ulcer care

OBJECTIVE

In 2004 the European Pressure Ulcer Advisory Panel nutritional working group developed a nutritional guideline for pressure ulcer prevention and treatment. This study investigated the degree to which the guideline was disseminated and implemented in clinical practice.

METHOD

A cross-sectional study was undertaken in health-care organisations in The Netherlands, Germany and the UK. A printed, standardised questionnaire which followed Rogers' model of the innovation-decision process was developed, translated and distributed to 1087 health-care organisations.

RESULTS

The response rate was 33% (n = 363). Sixty-one per cent of respondents knew of the guideline. Twenty-five per cent had applied it to their clinical practice and used it for nutritional screening. The main barrier to the provision of nutritional support appeared to be lack of knowledge and skills.

CONCLUSION

One year after its dissemination, more than half of respondents knew of the guideline, with one in four applying it to their practice. The guideline was better disseminated and implemented in The Netherlands and UK than in Germany, where only 4% of participants had used it.

Nutritional status and food intake in nine patients with chronic low-limb ulcers and pressure ulcers: importance of oral supplements

OBJECTIVES

Chronic low-limb ulcers and pressure ulcers are a serious and costly issue. Malnutrition is a risk factor. Searching for intervention strategies in elderly patients referred for surgical closure of their ulcers, the trial aimed at investigating the micronutrient status, determining the food intake of such patients, and the role of oral liquid supplements.

METHODS

Observational cohort study in 9 patients, starting 5 days prior to surgery until day 10 after surgery.

VARIABLES

body mass index (BMI), food intake assessed using standardized meals (energy target 25 kcal/kg/day). Oral liquid supplements were provided between meals. Laboratory: blood count, plasma proteins, antioxidant status, vitamins, Fe, Se, and Zn.

RESULTS

The patients were aged 71+/-10 y (mean+/-SD), with a BMI of 23.3+/-3.3. Baseline blood samples showed anemia and strong inflammation in 4 patients: albumin, retinol, and selenium were low; iron and zinc were very low. Food intake was largely variable and covered only about 76% (31-95%) of energy requirements. Breakfast provided 225+/-110, lunch 570+/-215, and dinner 405+/-150 kcal. Supplements were willingly consumed covering 35+/-12% of energy target. While vitamin supply was adequate, selenium and zinc requirements were not met.

CONCLUSIONS

Most patients with chronic skin ulcers suffered micronutrient status alterations, and borderline malnutrition. Meals did not cover energy requirements, while oral supplements covered basic micronutrient requirements and compensated for insufficient oral energy and protein intakes, justifying their use in hospitalized elderly patients.

Energy Requirements Are Not Greater in Elderly Patients Suffering from Pressure Ulcers

OBJECTIVES

To estimate energy requirements in diseased elderly patients with pressure ulcers (PUs).

DESIGN

Open, case-control study.

SETTING

University Hospital of Angers (France).

PARTICIPANTS

Twenty-nine patients with PUs (Norton index risk=14.3+/-3.3) and 27 controls hospitalized for various diseases (Norton=13.9+/-3.3).

MEASUREMENTS

Energy requirements were estimated using measured resting metabolic rate (RMR) and multiplied by 1.26 and 1.5 to range between minimal World Health Organization (WHO) requirements and those of adults undergoing light physical activity. Energy intakes were estimated using 3-day food weight records. Measured RMR was compared with the prediction equations of Harris-Benedict, WHO, and Schofield.

RESULTS

Measured RMR did not differ between the two groups (P=.48), and was not related to grade or size of the PUs. The WHO equation (82 kcal/d, P=.006) and the Schofield formula (57 kcal/d, P=.05) slightly underestimated calculated RMR, but the Harris-Benedict equation (40 kcal/d, P=.13) accurately estimated it. Energy requirements therefore ranged between 1,536+/-340 kcal/d and 1,828+/-405 kcal/d, (25-30 kcal/kg body weight per day). Energy intake was lower than energy requirements by 176 to 479 kcal/d.

CONCLUSION

Diseased elderly patients with PUs do not have greater energy expenditure, with their requirements suggested to range between 25 and 30 kcal/kg body weight per day. Malnutrition within this population is most likely the result of low energy intake.

The effectiveness of oral nutritional supplementation in the healing of pressure ulcers

OBJECTIVE

To investigate the effectiveness of an oral nutritional supplement that is rich in protein and enriched with arginine, vitamin C and zinc on the healing of pressure ulcers.

METHOD

Thirty-nine patients with grade III or IV pressure ulcers were enrolled into this open intervention study. Subjects received an oral nutritional supplement daily for three weeks. Wound area and the wound condition of the ulcers were assessed weekly.

RESULTS

After three weeks of supplementation, median wound area reduced significantly (p < 0.001) from 23.6 cm2 (1.6-176.6 cm2) to 19.2 cm2 (1.2-132.7 cm2), a reduction of 29%. Median healing of wound area was 0.34 cm2 per day, taking approximately two days to heal 1 cm2. Within three weeks the amount of exudate in infected ulcers (p = 0.012) and the incidence of necrotic tissue (p = 0.001) reduced significantly.

CONCLUSION

Nutritional intervention in the form of a specific oral nutritional supplement resulted in a significant reduction in wound area and an improvement in wound condition in patients with grade III and IV pressure ulcers within three weeks.

Old age, malnutrition, and pressure sores: an ill-fated alliance

Wound healing is a complex, tightly regulated process, consisting of three distinct phases. In each phase of wound healing, energy and macronutrients are required. Moreover, animal studies have established a specific role for certain nutrients such as the amino acid arginine, the vitamins A, B, and C, and the elements selenium, manganese, zinc, and copper. Chronic wounds such as pressure ulcers have extensively been investigated as to the risk of development, prevention, and cure. Here, the combination of old age, malnutrition, and pressure ulcers is highly unfortunate. Energy and nutrients, such as proteins and vitamins B and C, being deficient at old age are needed in pressure ulcer healing. Malnutrition is associated with skin anergy and with immobility because of mental apathy and muscle wasting. Severe malnutrition, impaired oral intake, and the risk of pressure ulcer formation appear to be interrelated. Adequate nutrition may reverse the underfed state unless an underlying wasting disease was present and appeared to reduce the prevalence and incidence in cross-sectional and prospective observational studies. However, attempts to prevent pressure ulcers by nutritional intervention were divergent in outcome, reflecting the difficulties to meet the daily requirements in elderly persons and the lack of knowledge about true nutritional needs in wound healing. The consumption of a diet high in protein and energy may promote pressure ulcer healing. When considering nutritional support, oral supplementation should be weighted against tube feeding, as the associated morbidity of tube feeding, i.e., diarrhea, fecal incontinence, and restricted mobility being in themselves risk factors for pressure ulcers, might obscure the favorable effects of adequate nutrition. Despite the evidence in animal studies, none of the above-mentioned specific nutrients promoted the healing of pressure ulcers in humans. Therefore, the attention should be focused on early recognition of a depleted nutritional status and an adequate and supervised intake of energy (35 kcal/kg) and protein (1.5 g/kg) with provision of the recommended daily allowances of micronutrients and with correction of the nutrient deficiencies of old age.

Nutritional intervention in pressure ulcer guidelines

Nutritional data from the literature and the high prevalence of malnutrition in patients at risk of pressure ulcers (PUs) or with established PU mandate structural nutritional actions in these patients. Guidelines can help to improve nutritional alertness in professionals and promote structural nutritional assessment and nutritional intervention in PU-prone or PU patients. PU guidelines from 13 countries were compared with regard to nutritional management of PU patients. The attention paid to nutritional prevention and treatment in PU patients varied considerably across guidelines. Recommendations with regard to nutritional intervention should be incorporated transparently into PU guidelines and should be complete, specific, testable, and cover the entire nutritional cycle.

Nutritional intake of hazardous drinkers and dependent alcoholics in the UK

There are no recent assessments of nutritional intake in alcohol misusers in the United Kingdom. The purpose of this study was to measure nutritional intake in alcoholics attending an Alcohol Misuse outpatient clinic in an inner city general hospital in the United Kingdom and relating this to various measures of alcohol dependence. All patients (n = 30; 27 male, 3 female) consumed at least 100 g ethanol per day (mean 162 g/day) for at least 5 years and completed questionnaires on socio-demographics, alcohol dependency and psychosocial problems and had assays of biochemical and haematological indices. The data were analysed first with respect to the entire patient population and then according to the degree of alcohol dependency (mild, moderate or severe). The results showed that with respect to the entire patient group, one-third were below normal body weights, but one-quarter was overweight. The total energy intake (kJ/day) including alcohol was apparently adequate with respect to recommended levels in most patients. On average, approx. 60% of energy intake came from alcohol. The whole patient population had a low intake of one or more macro- and micro-nutrient compared to the dietary reference requirements. All patients had intakes of vitamin E and folate below UK recommended standards, while 85 - 95% of patients had low intakes of selenium and Vitamin D. Between 50 and 85% of all patents had intakes below UK recommended standards in calcium and zinc and Vitamins A, B(1), B(2), B(6) and C. There were significant correlations between calorie intake (when alcohol was excluded) and vitamins B(1), B(2), B(6) and C, and Ca, Mg, Fe and Zn intake. There were no correlations between alcohol intake with any of the nutritional and anthropometric variables or between the three subgroups with respect to daily energy, micro- and macro-nutrient intakes. In conclusion, malnutrition was common in this patient group: all subjects had intakes below UK recommended standards in one or more micro- or macro-nutrient. However, there was no difference in the degree of malnutrition between the harmful drinkers (mild dependency) and heavily dependent subgroups.

Treatment of pressure ulcers by serial casting in patients with severe spasticity of cerebral origin

OBJECTIVE

To assess the effectiveness of serial casting in the treatment of pressure ulcers caused by severe spasticity.

DESIGN

Case series.

SETTING

A clinic for the rehabilitation of persons with neurologic disorders.

PATIENTS

Nine patients with 11 pressure ulcers resulting from severe cerebral spasticity, the ulcers being intractable to conventional management because of repeated friction and/or inaccessibility.

INTERVENTION

Serial casting of the limb(s) with the pressure ulcer(s), with either fenestration or a cast arch providing access to the wound.

MAIN OUTCOME MEASURES

Improved healing of pressure ulcers, as quantified with the National Pressure Ulcer Advisory Panel classification system.

RESULTS

Within a mean of 4.6 weeks, 7 ulcers healed completely and 4 improved markedly. The casting caused no complications. Moreover, extension deficits improved markedly in all patients (105 degrees +/- 27 degrees to 17 degrees +/- 10 degrees ).

CONCLUSION

Serial casting may be a valuable tool in the treatment of pressure ulcers at the extremities of patients with severe cerebral spasticity.