Skin, Wounds, and Nutrition Part 4

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