Nutrition Intervention in Pressure Ulcers
Nutritional Intervention for Pressure Ulcers
I am always interested in the aspects of wound healing in varying disease settings. One of the more complex, costly and debilitating wounds is that of pressure ulcers (PU). These painful, debilitating wounds are most common in vulnerable patients; the elderly, the chronically ill and the functionally disabled. According to the Agency for Healthcare Research Pressure Ulcers, PU are one of the patient safety measures affecting quality of life.
The treatment of PU is often multimodality. Aggressive positioning of the patient, control of bodily fluids, treatment of co-morbid disease processes and medication and surgical management are often maximized. However, one of the most commonly overlooked aspects is nutritional interventions. Recently, an Advisory Panel (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Alliance and Pan Pacific Pressure Ulcer Alliance) came together to construct a white paper on the role of nutrition for pressure ulcer management (Adv Skin Care Wound Care, April 2015).
This white paper pointed out that the National Pressure Ulcer Long-Term Care Study reported that eating problems were associated with a higher risk of developing PU. They noted that an Australian Queensland public hospital patient report from 2002-3003 found that 1/3 of PU were attributable directly to malnutrition with an annual cost in that one environment of approximately 13 million dollars AU (10.4 million dollars US). Globally and in the US this figure is obviously many, many times that number.
Assessing malnutrition can be difficult. Protein markers (Albumin and Prealbumin) may help identify some patients at malnutrition risk but is far from perfect and does not generally reflect when nutrition interventions begins to restore a patient’s nutritional status. We know that inflammation is a large component of PU pathology. Inflammation leads to a suppression of the production of serum albumin and prealbumin, irrespective of the nutritional status. Inflammation also leads to a decrease in lean body mass (muscle) which is linked to poor wound healing and functional disability. The effects of inflammation multiply the impact of malnutrition, a deficiency of energy, protein and/or nutrients, on PU healing. Overall, the majority of patients with PU have chronic medical conditions that make the likelihood of adequate nutritional intake or nutrient metabolism unlikely. It is nearly impossible for aggressive medical and surgical PU treatments to work in the face of malnutrition.
The White Paper appropriately points out that when energy (fat and glucose calories) are undersupplied that the body often resorts to using some lean body mass as energy further depleting a patient’s muscle stores. However, protein intake is very important. All stages of wound healing require adequate protein. This White Paper’s Task Force points out that the Trans-Tasman Evidence-Based guidelines for Dietetic Management for Adults with Pressure Ulcers recommends 1.25 – 1.5 g/kg/day body weight of protein intake daily for patients at moderate or high risk for delayed healing for PU. In fact, this may underestimate the needed amount of protein.
Elderly patients are already sarcopenic (they have reduced muscle lean body mass based on age-related physiologic changes). When these patients are chronically ill and “inflamed” their overall protein needs may skyrocket. Analysis of protein needs in the PU patient in the literature by standard laboratory techniques (such as radioisotope trace protein flux assessment) simply do not exist or do not help establish a firm protein quantity need. However, evaluation of patients who are critically ill (also with elevated inflammatory states) would suggest that protein needs are much higher. In addition, we know that providing adequate vitamins and trace minerals are also important for overall wound healing and functional status although there is no good evidence that extra-large “pharmacologic” doses of vitamins (like vitamin C) or trace minerals (like zinc) are effective for promoting wound healing.
A typical approach to PU treatment from a nutritional intervention perspective is oral supplementation (eat more or drink an oral supplement). A recent provocative study was published by Cerda on an oral nutritional formula that seemed to improve PU healing (See my next blog to come for a review of this article). A 2014 Cochrane analysis of studies of nutritional intervention (mostly oral supplements but a few enteral feeding studies) was inconclusive for the effectiveness of nutrition for PU healing. However, with all due respect, these studies lacked adequate powering, were suspect in design, did not control for other treatment interventions well and certainly did not come close to providing adequate protein to the patient; why would they be positive?
Perhaps it is time for a change. I am all in favor of oral supplementation as an initial intervention to treat malnutrition and address protein needs of patients with PU. However, if in a short period of time (days) if it is apparent that the patient cannot consume consistently the amount of nutrition orally that would meet the increased protein and other nutrient needs of a PU patient, a higher degree of intervention should be considered in a timely fashion. This would be the provision of protein and nutrients by enteral or parenteral nutrition. The most important point is that the protein and nutrients must be delivered consistently from day to day without a day or days of not reaching target nutrition goals. We would not sit back and accept ½ the delivery of wound care medical management but are often willing to accept ½ the delivery of protein and other nutrients. Why?
The White paper’s combined Task Force has a series of conclusive “practice pearls.” They are:
- Nutrition screening of all patients at risk or with a PU
- Collaborate with a nutrition professional for nutrition treatments
- Implement the Task Force’s guidelines
- Encourage consumption of a balance diet
- Offer oral nutrition supplements (ONS) between meals if appropriate
- Consider enteral or parenteral nutrition if oral intake is inadequate.
Pressure Ulcers are a nasty disease and a huge quality of life and economic burden. Let’s move from observers of nutrition to “interventionalists” of nutrition. Don’t be afraid to appropriately “step-up” your nutrition intervention when needed. Most of all, be vocal, be bold and carefully track your clinical outcomes.
Dr. DeLegge Bio
Dr. DeLegge is board certified in internal medicine, gastroenterology and nutrition. He manages patients with complex medical problems such as malabsorption and short bowel syndrome. He also is the specialist for placement of feeding tubes in the gastrointestinal tract, and the subsequent management of those patients. His nutrition research focuses on nutritional assessment, parenteral nutrition and enteral nutrition.
Mark DeLegge, MD
Professor of Medicine
Medical University of South Carolina