Nutrition and healing QPG 2017.ppt -...

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Medicine, Nursing and Health Sciences

The role of nutrition in wound healingQuality Pharmacy Training 2017

Associate Professor Geoff SussmanClayton Campus

The role of nutrition in wound healing

The role of nutrition and its influence on wound healing was recognised as far back as the time of Hippocrates.

Clearly the problem is complex and multifactorial. Secondly it is important to note that the role of nutrition and the success of nutritional intervention will depend on the aetiology of the wound.

The role of nutrition in wound healingAre all wounds the same?

What are the differences between a surgical wound, a pressure ulcer, a leg ulcer and a Diabetic wound?

The process of wound healing is similar to all wounds but wounds vary greatly depending on the underlying aetiology, size, severity, and location of the wound. Consequently the impact of nutrition will vary in most cases, but there are some commonality in the process of wound healing such as the need for protein, other macronutrients and micronutrients.


Macro and Micronutrients play an

important role in the stimulation and

activity of growth factors and cytokines


There are a number of factors that affect wound healing and that in turn are also influenced by the nutritional status of the individual.

In some cases such as in the effect of sepsis both wound healing and the nutritional status of the patient are adversely affected.

Nutrition in acute wound failure

Failure of acute wound healing leads to fascial dehiscence, wound infection, incisional hernias, anastomotic leak, and fistulas. It is well documented that malnourished patients have a higher risk of death, sepsis and increased length of stay.

Nutritional support becomes obligatory if the patient is unable to eat for prolonged periods of time such as in the case of major abdominal wound dehiscence.

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Timing of nutritional support

Human studies have shown changes in collagen accumulation as a result of timing of feeding and that a short preoperative illness that precluded optimal nutrient intake lead to adverse postoperative wound healing.

Preoperative nutritional intake was influential in collagen deposition following abdominal surgery. Patients who ate well preoperatively regardless of their nutritional markers still deposited significantly more collagen than patients who ate poorly.

Chronic wounds

Chronic wounds all have an underlying systemic pathology which disrupt the orderly process of wound healing, though there is no agreed upon definition in what constitutes a “chronic wound”. Chronic wounds exhibit a chronic inflammatory phenomenon.

Chronic wounds in which the role of nutrition has been studied can be arranged into three major groups. They include diabetic, venous and pressure ulcers. They often heal by secondary intention

Pressure Ulcers – décubitus ulcers

There has been increased interest in the development of pressure ulceration (PU) in the past few years. Its epidemiology mirrors that of immobility, and therefore the highest incidence is to be found in the disabled, those in hospital or those in a long-term care.

Pressure Ulcers – décubitus ulcers

Its incidence has been reported to be to range between 3 to 26%. The majority ie 60% of those who develop PU do so in a hospital setting and the remaining 40% are roughly divided equally between home and nursing home. Such non-healing wounds place a severe burden on the health care system and cause significant suffering.

Factors causing Pressure Ulcers

Local factors Systemic factors

Pressure sustained causing ischaemia

Age

Friction- causing mechanical pressure

Nutritional status

Moisture

Hypotension/ Presence of co-morbidity/ general health condition

Physical activity.

Macronutrients and Fluid and Wound Healing

Since wound healing may be inhibited by

tissue hypoxaemia, the risk of decreased

oxygen tension secondary to interstitial fluid

accumulation should be further evaluated in

studies of low v high fluid administration.

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The body requires all major macronutrients

for tissue repair

Fluid Protein Fat Carbohydrates


Chronic wounds can be very exudative and

the loss of fluid daily can amount to litres.

The replacement of such fluid and often

Albumin and electrolytes is not usually

considered as part of the management of

the wound


Severe systemic edema continues to be a

Major complication following burn injury.

Although attempts have been made to limit

edema formation by modifying the resuscitative

regimen, no single fluid resuscitation formula

has proven to be superior


Thuan T. Nguyen,., David A. Gilpin,., Nicholas A. Meyer, and David N. Herndon,.ANNALS OF SURGERY Vol. 223, No. 1, 14-25 1996

Macronutrients

Macronutrients provide the energy for all

functions of the body. They are the major

building blocks for all tissues and the

reparative process.

The main macronutrients are

Carbohydrates

Fat

Protein

Carbohydrates

Calories are required for the energy necessary

for wound healing.

Skin cells are glucose dependant for energy in

cutaneous wound healing however excessively

high levels (hyperglycemia) have a negative

impact on wound healing.

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Carbohydrates

Interestingly sugars have been used topically in

infected wounds for many years. Due to their

high osmotic concentration sugar solutions eg.

Honey will kills bacteria by removing the

intracellular fluid for the cells

Fats

Fats play a number of roles in the body

providing a source of energy and they act as

signalling molecules. Specific fatty acids

secreted through the skin also help control

the levels of skin bacterial flora.

Fats

The healing process in most wounds requires

an increase in caloric intake over basal levels.

It is important to understand the healing

cascade and the phases of wound healing and

Where nutrients influence wound healing.

Fats

The role of essential fatty acids in wound

healing is the modulation of inflammation and

the immune response.

Omega 3: Anti-inflammatory properties

Omega 6: Primarily pro-inflammatory

The use of Omega 3 fatty acids in the early

Stages of a wound may delay healing.

Fats

High fat intake can result in in fatty infiltration of

the liver. An excess of Omega 3 fatty acids may

turn into immunosuppression this can be a

complicating factor in wound patients who have

local or systemic infection. Also an excess of

Omega 6 fatty acids may exacerbate

inflammation which needs to be controlled.

FatsPlasma Phospholipid Fatty Acids and Prostate Cancer Risk Studies of dietary ω-3 fatty acid intake and prostate cancer risk

are inconsistent; however, recent large prospective studies

found increased risk of prostate cancer among men with high

Blood concentrations of long-chain ω-3 polyunsaturated acids.

Compared with men in the lowest quartiles of LCω-3PUFA,

men in the highest quartile had increased risks for low-grade

(HR = 1.44, 95% CI = 1.08 to 1.93), high-grade (HR = 1.71,

95% CI = 1.00 to 2.94)

Theodore M Brasky et al Plasma Phospholipid Fatty Acids and Prostate Cancer Risk in the SELECT Trial JNCI Natl Cancer Inst July 10, 2013

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Protein

For sound wound healing dietary protein is

essential. A lack of protein impairs wound

healing by prolonging the inflammatory phase,

Impairing fibroplasia, collagen and proteoglycan

Syntheses and impairing cross-linking of

Collagen and the ECM

Protein

High protein diets are associated with increased healing

of pressure ulcers. The role of specific amino acids in

particular Arginine and Glutamine have been studied

And they play an very important role in wound Healing.

Other amino acids which influence wound healing

include Methionine and Cysteine which aids fibroblast

proliferation and collagen synthesis. Essential amino

acids are primarily responsible for the amino acid stimulation of muscle protein anabolism

The ‘Rose’ classification of amino acids

EssentialLysineTryptophanePhenylalanine + tyrosine Leucine Isoleucine Valine Threonine Methionine + cystine Histidine

Rose WC: The amino acid requirement

of adult man. Nutr Abstr Rev 1957;27:631–647.

The ‘Rose’ classification of amino acids

NonessentialGlycineAlanineSerineCystineTyrosineAspartic acidGlutamic acidProlineHydroxyprolineHistidineCitrullineArginine

Rose WC: The amino acid requirement

of adult man. Nutr Abstr Rev 1957;27:631–647.

Arginine

Arginine is a basic amino acid that plays several

pivotal roles in cellular physiology. Like any amino

acid, it is involved with protein synthesis, but it is also

Intimately involved with cell signaling through the

production of nitric oxide and cell proliferation.

Arginine is one of the most metabolically versatile

amino acids. It serves as a precursor for the

synthesis of Urea, nitric oxide, polyamines, proline,

glutamine, creatine, and agmantineMARIA B. WITTE,; ADRIAN BARBUL, WOUND REP REG 2003;11:419–423

Arginine

S Morris Am Jur Clin Nut 2006(supp) 508S-12S

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Arginine

Arginine can be provided via nutritional intake

or via new synthesis. Citrulline, generated

from glutamine in the small intestine, is the

Major precursor for arginine.

About 50% of the ingested arginine is released

into the portal circulation. The other part is

directly utilized in the small bowel.

MARIA B. WITTE,; ADRIAN BARBUL, WOUND REP REG 2003;11:419–423

Arginine

The physiological uptake of arginine and

citrulline by the liver is low because the liver

does not express large amounts of the cationic

transporter for the basic amino acid arginine


Arginine

Arginine catabolism occurs via several enzymatic

pathways The two major catabolic pathways

during wound healing are degradation via NO

Synthase (NOS) isoforms and via the two arginase

isoforms. Both pathways deplete extracellular

arginine concentrations in the wound milieu, thus

rendering arginine an essential amino acid for wound

healingMARIA B. WITTE,; ADRIAN BARBUL, WOUND REP REG 2003;11:419–423

Arginine

Transforming growth factor-beta, for example,

stimulates arginase but inhibits inducible (Nitric

Oxide Synthase) NOS and isoforms

(iNOS). As both pathways are induced in

The wound in a time-coordinated manner, the

stringency of this reciprocal regulation ensures

Effective wound healing.


Arginine

Enriching the Arginine intake in humans and

Rodents has a significant effect on wound healing.

Dietary arginine supplementation has Been Shown to

improve collagen deposition and wound strength in

human and animal models.

Although the doses of arginine administered

(200–500 mg/kg/day) must be considered

‘‘pharmacological,’’ there is a notable lack of

toxic side-effects. .


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Arginine

Biologically or nutritionally intravenous or

enteral administration of arginine appears

equally effective. Although the exact

mechanisms of action of arginine on

Collagen metabolism and wound healing are

not known, there are several likely pathways


Arginine

Collagen synthesis is essential for scar

formation, which is the basis for most

mammalian healing. The extra cellular

matrix(ECM) provides the tensile strength to

Tissue. The newly deposited collagen must be

considered in terms of quality and quantity.


Arginine

Starting with the premise that arginine may

become essential after surgery and wounding,

Seifter et al.showed that arginine is not

essential for normal growth and development

but becomes so in post-traumatic situations.

Seifter E, Rettura G, Barbul A, Levenson SM.Arginine: an essential amino acid for injured rats. Surgery

1978;84:224–30).

Arginine

Immune modulation and infection

Another important biologic effect of

supplemental arginine is its unique effect on

T-cell function. Arginine acts as a thymotropic

agent and stimulates in vitro and in vivoT-cell

responses. Arginine also reduces or abrogates

the negative effect of injury on T-cell function


Arginine


In healthy humans, arginine enhances the mitogenic

activity of peripheral blood lymphocytes and greatly

reduces post-Traumatic impairment in lymphocyte

blastogenesis.

More recently, arginine has been shown to be

critical for bone marrow B-lymphocyte differentiation


Arginine


lymphocyte differentiation.T-lymphocytes are essential

for normal wound healing.

T-cell depleted mice and rats have a significantly

impaired wound healing response compared to normal

animals. It is therefore possible that arginine

Enhances wound healing responses by stimulating

host and wound T-cell responses, which then increase

Fibroblastic responses.


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Arginine

Endocrine/secretagogue effects

One of the well-known biological effects of

arginine is its very potent secretagogue activity

on the pituitary and pancreatic glands

Supplemental arginine on wound healing are

similar to the effects noted when growth

hormone is administered to wounded animals

or burned children


Arginine


The response of healthy elderly human

Volunteers given 2 weeks of dietary

supplementation with 30 g of arginine aspartate

is enhanced wound collagen Accumulation

together with a significant elevation in

Circulating IGF-1.


Arginine


This suggests that arginine does stimulate

pituitary activity in the doses used and that

this may be one of the mechanisms of action

underlying its beneficial effect on wound

healing


Food sources of Arginine

Watermelon is a rich source of citrulline, an amino acid that can be metabolized to arginine, a conditionally essential amino acid for humans. Arginine is the nitrogenous substrate used in the synthesis of nitric oxide and plays an essential role in cardiovascular and immune functions. A study used 780, or 1560 g of watermelon juice per day for 3 week in a crossover design..

Julie K. Collins et al Nutrition 23 (2007) 261–266


The treatments provided 1 and 2 g of citrulline per day. Compared with the baseline, fasting plasma arginine concentrations increased 12% after 3 week of the lower-dose watermelon treatment; arginine concentrations increased 22% after 3 week of the higher-dose watermelon treatment. These results demonstrate that plasma concentration of arginine can be increased through intake of citrulline from watermelon.

Julie K. Collins et al Nutrition 23 (2007) 261–266


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kcal/mL: 0.63 Caloric Distribution (% of kcal) Protein: 19% Carbohydrate: 81% Fat: 0% Protein Source: whey protein isolate (milk), L-arginine NPC:N Ratio:76:1 Osmolality (mOsm/kg water): 380 Free Water: 89% Supplemental L-Arginine: 3.0 g/237 mL HCPCS Code:B4102

Appropriate for these diets: lactose-free*, gluten-free, kosher, fat-free

Resource DiabetishieldArginaid

kcal/mL: 0.15 when mixed with 237 mL water Caloric Distribution (% of kcal) Protein: 53% Carbohydrate:47% Fat: 0% Protein Source: L-arginine Osmolality (mOsm/kg water): 170 when mixed with 237 mL water Supplemental L-Arginine: 4.5 g/servingHCPCS Code: B4155Appropriate for these diets: lactose-free*, gluten-free, kosher, sugar-free

Resource Arginaid Extra

kcal/mL: 1.06 Caloric Distribution (% of kcal) Protein: 17% Carbohydrate: 83% Fat: 0% Protein Source: whey protein isolate, L-arginine NPC:N Ratio: 94:1 Osmolality (mOsm/kg water): 1340 Free Water: 83% Supplemental L-Arginine: 4.5 g/237 mL Vitamin C: 250 mg/237 mL Vitamin E: 90 IU/237 mL Zinc: 15 mg/237 mL HCPCS Code: B4102 Appropriate for these diets:lactose-free*, gluten-free, low-residue, kosher

Cubitan1.25 kcal/mL

Very high protein; 20g protein per 200mL bottle

(30%En) to facilitate wound healing Arginine enriched: 3 g/200mL

bottle to stimulate wound healing

Omega 6: Omega 3 ratio 5:1 supporting improved patient immunity

Enriched Vitamin C content (250mg per 200mL bottle) for its

antioxidant properties and assistance with collagen synthesis

Enriched zinc content (9mg per 200ml bottle) to enhance tissue

Regeneration Enriched Vitamin E content (38mg per 200mL bottle)

for its antioxidant properties in preventing free radical formation

Added carotenoids and flavonoids to regulate inflammatory

processes Gluten free Osmolality 625 mOsm/kg H2O Delicious

vanilla flavour to encourage patient compliance

Enprocal Repair

1. Fortified with L-arginine (2.1g per 17.5g sachet)Arginine is a semi-essential amino acid which has a proven association with improved rates of recovery from wounds.

2. High level of whey protein concentrateEnprocal Repair consists of 42.8% protein; the majority of which is Whey Protein Concentrate (WPC).

3. High levels of energy and key micronutrients,including fibre, calcium, zinc, vitamins C, D, A, B1, B2, B6, B12 and folate.

4. Gluten freeEnprocal Repair is gluten free and suitable (after dietitian review) for most diabetics. As a milk-based product, it should not be used by persons with clinical lactose intolerance or milk allergies.

Conclusion

Studies have clearly indicated the role of

L-Arginine in wound healing. The evidence is

Strongest in the treatment of Pressure Ulcers.

Further studies need to be undertaken to

Strengthen our knowledge of the role of

Arginine in wound healing in general

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Protein Toxicity

Excess protein may cause serious metabolic

complications. These include acidosis. In

surplus protein feeding the nitrogen of the

amino acids is broken down to ammonia and

then urea. Increased renal urea excretion

Requires appropriate water excretion.

Over feeding protein with inadequate water can

produce hypertonic dehydration.

Micronutrients

Micronutrient deficiency not only causes

symptoms of severe deficiency, but

may also cause more subtle effects on

Tissue function, including immune

Deficiency and oxidative damage.

Micronutrients

Micronutrients act as cofactors in many

pathways and are critical to all activities of

Macronutrients. Included in micronutrients are:

Vitamins Minerals Trace Elements

Micronutrients

VitaminsVitamin AVitamin B complexVitamin DVitamin EVitamin K

Micronutrients

Minerals Zinc

Iron

Copper

Micronutrients

Trace Elements Boron Chromium Iodine Manganese Selenium Silicon Silver

Electrolytes Sodium Potassium Calcium

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Micronutrients

Micronutrient support of wound healing is

Accomplished by means of enteral and/or

parenteral routes, Although certain

nutrients play important roles in wound-

healing physiology, the value of

supplementing patients who are not

deficient remains unproved.Jeffrey I. MechanickThe American Journal of Surgery 188 (Suppl to July 2004) 52S–56S

Micronutrients

Glutamine is a conditionally essential amino acid and

may promote nitrogen balance , gut absorptive function

and immune function. Arginine is also a conditionally

essential amino acid that improves wound healing

and immune function Ornithine -ketoglutarate is

a precursor of glutamine, arginine, proline, and –

ketoisocaproate,and can regulate protein metabolism,

Influence secretion of insulin and growth hormone,

and improve wound healingJeffrey I. MechanickThe American Journal of Surgery 188 (Suppl to July 2004) 52S–56S

ALAN SHENKIN ,Nutrition Vol: 13, No. 9, 1997

Micronutrients have a range of functions to prevent

oxidative damage to polyunsaturated fatty acids in

cell membranes,and to DNA within all cells. Zinc,

copper,and manganese are all involved in the

Superoxide dismutase enzymes in mitochondria

and the cytoplasm, and selenium is part of the

glutathione peroxidase enzyme system, which helps

to dispose of hydrogen peroxide.

Micronutrients and Antioxidant Function

ALAN SHENKIN ,Nutrition Vol: 13, No. 9, 1997

Micronutrients and Antioxidant Function

Moreover vitamin E, vitamin A, and carotene

are lipophilic antioxidants in cell membrane

structures, vitamin C being the major

Cytoplasmic antioxidant.

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Vitamin A

Vitamin A improves cell-mediated immunity; is

necessary for wound debridement, fibroplasia

and epithelialization; and improves collagen

synthesis and cross-linking.

It plays a unique role in counteracting the

delay in wound healing caused by steroids,

diabetes, and radiation damage.

Connie L. Harris, Chris Fraser, Ostomy Wound Management 2004 50(10);

Vitamin A

Vitamin A deficiency causes increased susceptibility

to infections and decreases epithelialization and

collagen and granulation tissue development in the

proliferative stages of wound healing.

Some potential symptoms of vitamin A deficiency

include dry skin, taste and smell impairment, follicular

hyperkeratosis, and corneal or conjunctival dryness. Connie L. Harris, Chris Fraser, Ostomy Wound Management 2004 50(10);

Vitamin B Group

Thiamine, riboflavin, pyridoxine (vitamin B6),

folic acid, and pantothenate are B vitamins that

assist in leukocyte formation, participate in

metabolic processes necessary to provide

energy required for the anabolic process of

wound healing, and are essential cofactors in

enzyme activity.


Vitamin B Group

Thiamine, riboflavin, vitamin B12, and

pyridoxine are Necessary for collagen matrix

synthesis.

Deficiencies have an indirect effect on wound

healing by decreasing host resistance because

of impaired antibody formation and white blood

cell function, which also increases

susceptibility to infections


Vitamin CVitamin C is necessary for optimal immune response,

cell mitosis, and monocyte migration into the wound

tissue that transforms into macrophages during the

inflammatory phase of wound healing. Vitamin C

uptake increases during phagocytosis of debris and

bacteria by macrophages; thereby, controlling

infection. An antioxidant, vitamin C destroys free

radicals that are by-products of oxidation and can

damage healthy cells. Connie L. Harris, Chris Fraser, Ostomy Wound Management 2004 50(10);

Vitamin C

Vitamin C forms bonds between the collagen fiber strands,

providing extra stability and strength. If these bonds are not

formed within the cell, the collagen will be rapidly broken down

by collagenase, an enzyme found in the extracellular fluid. In

addition, vitamin C is essential for angiogenesis; vitamin C

deficiencies cause increased capillary fragility, decreased

wound strength, wound dehiscence, and impaired collagen

production.


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Vitamin CThe metabolic stress of a pressure ulcer increases

the requirement for vitamin C, and studies have

suggested that the concentration of vitamin C rises in

healing tissue Some potential physical signs of

vitamin C deficiency include bruising, purpura,

petechiae around hair follicles, and swollen, spongy

and/or bleeding gums. There is some evidence that

Supplemented vitamin C may accelerate wound healing in

the absence of clinical deficiency


Vitamin D

Vitamin D plays and important role in the

stimulation of the parathyroid gland for the

absorption of Calcium.

Vitamin D has been shown to regulate

growth and differentiation of cells eg B & T

Lymphocytes, Melanocytes, Fibroblasts,

Endothelial cells and Macrophages.

M Gottschlich Nutrition and Wound Healing 2007

Vitamin D Diabetes

Vitamin D in fact is not a vitamin it is a hormone, It plays an increasingly important role in many aspects of the bodies functions. A lack of this hormone has been shown to be a major factors in the development of Multiple Sclerosis, and has a major influence in the development of cancers, cardiovascular diseases and Diabetes

Vitamin D Diabetes

In addition to its role in calcium homeostasis and bone health, vitamin D has also been reported to have anticancer activities against many cancer types, including breast cancer. The discovery that breast epithelial cells possess the same enzymatic system as the kidney, allowing local manufacture of active vitamin D from circulating precursors, makes the effect of vitamin D in breast cancer biologically plausible. Preclinical and ecologic studies have suggested a role for vitamin D in breast cancer prevention.

Vitamin E

Oral vitamin E is contraindicated during

pressure ulcer management because it

interferes with collagen synthesis, scavenges

oxygen in the vicinity of the wound, prolongs

the inflammatory phase of wound healing, and

may interfere with the beneficial roles of vitamin

A in wound management.


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Vitamin K

Vitamin K is essential in the clotting process but

contributes little to wound healing. However,

vitamin K deficiency contributes to decreased

coagulation, which impairs the inflammatory

phases of wound healing.

Zinc

Zinc was identified as an essential micronutrient by

The Wisconsin group of biochemists in 1934. The

nutritional value of zinc was widely researched by

McCance and Widdowson in the 1940s but the true

clinical significance of zinc was not appreciated until

much later

Alan B. G. Lansdown,; Ursula Mirastschijski,; Nicky Stubbs, Elizabeth Scanlon,; Magnus S. Ågren, Wound Repair & Regeneration Volume 15, Issue 1, Pages 2-16

ZincThe body requirements for zinc in humans are

normally satisfied by a well-balanced diet leading to

an average daily intake of 10–15 mg per day in

concordance with the recommended daily allowance

For zinc in healthy adults of 8–15 mg per day. Diets

rich in protein are usually high in zinc, whereas

vegetable diets containing high plant fiber are low in

absorbable zinc


Zinc

zinc deficiency is related to impaired wound

healing, but there is controversy over the value of

zinc supplements in surgical wounds, the best

evidence relating to healing of cutaneous leg ulcers.

Effect of topical zinc on normal and impaired wound healing

Zinc is more commonly used topically, although

it is unclear when zinc was first used in the

management of skin wounds. Pharmacopoeias

list zinc sulfate as a local astringent and

antiseptic, zinc chloride as an escharotic, and

insoluble zinc oxide and calamine as mild

antiseptics, astringents, and protective agents,

with particular value in treating inflammatory

skin conditions and superficial wounds.


Effect of topical zinc on normal and impaired wound healing

Zinc stimulates epithelialization more than

wound contraction in experimental wounds. In

support of this, results from clinical trials

indicate the beneficial effects of topical zinc on

human wounds healing predominantly by

epithelialization


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Effect of topical zinc

At super physiological levels, zinc inhibits the growth

of several bacterial species. Gram-positive organisms

appear to be more sensitive to zinc than Gram-

negative bacteria. For example, minimum inhibitory

concentrations (MICs) of Zn2+ on aerobic bacteria

isolated from human wound infections were

determined in one study.



Intriguingly, topical zinc reduced oral antibiotic

consumption significantly compared with

placebo treatment. Furthermore,

Staphylococcus aureus was cultured

significantly less frequently from zinc oxide-

treated than from placebo-treated wounds,

substantiating its mild anecdotal antiseptic

property



Four susceptibility grades emerged from the study:

1. Streptococcus groups A, C, and G (MICs ≤0.5–2 mmol/L);

2. Staphylococcus aureus, Streptococcus group B (MICs 2–4 mmol/L);

3. Escherichia coli, Klebsiella sp., Enterobacter sp. (MICs 4–8 mmol/L);

4. Proteus sp., Pseudomonas aeruginosa, Enterococcus sp. (MICs 8–32 mmol/L).


Effect of systemic zinc supplementation and chronic wound healing

The majority of studies designed to determine

the efficacy of systemic zinc in wound healing

have been conducted in patients with chronic

wounds. Chronic leg ulcer patients often have

abnormal zinc metabolism and low serum zinc

levels.


Effect of systemic zinc supplementation and chronic wound healing

A recent appraisal concluded that no trial has

shown a statistically significant benefit for zinc

sulfate in leg ulcer therapy unless there is

evidence of low serum zinc. The adverse

effects of oral zinc sulfate, usually given as

capsules or tablets containing 220 mg thrice

daily, include abdominal pain, dyspepsia,

nausea, vomiting, and diarrhea.Alan B. G. Lansdown,; Ursula Mirastschijski,; Nicky Stubbs, Elizabeth Scanlon,; Magnus

S. Ågren, Wound Repair & Regeneration Volume 15, Issue 1, Pages 2-16

IronIron is necessary for optimizing tissue perfusion by

transporting oxygen to the tissues and is necessary

for collagen synthesis. A deficiency may cause

increased tissue ischemia, impaired collagen cross-

linking, and decreased wound strength. Possible

symptoms of iron deficiency include loss of energy

(mild fatigue to exhaustion), pallor, sore tongue,

digestive tract disturbances, appetite disorders,

and brittle spoon-shaped nails.


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Attention for nutrition…; why?

If there are problems with nutrition…:

Child: failure to thrive; problems regarding growth and development

Patient with acute disease:

complications and/or disturbed recovery

Frail elderly: failure to thrive;

entering the downward spiral

various authors

Woundcare: Focus on Pressure ulcers - PU

PU are the result of a complex interplay between extrinsic and intrinsic risk factors!

Extrinsic e.g.:pressure and shear forces

Intrinsic e.g.:age, morbidity, handicap status,

urinal and/or faecal incontinence

and also….nutritional status!!

a PU outside is also an indication of frailty inside…!!

Pressure ulcers are mostly located on sacrum and heel; they are common in:

Geriatric patients (characterized by frailty, comorbidity and disability)

Chronic care patients (e.g. in nursing homes), Patients with limited mobility, Patients with malnutrition!

Pressure ulcers are associated with:

Increased morbidity

Increased mortality

Local and systemic infections

Quality of life issues: pain, smell, exudate, body image, healing a.s.o.

Pressure ulcers are associated with:

Huge health care costs

LPZ 2006, Stratton et al 2003, Baumgarten et al 2003, Bennett et al. 2004

Essentials of PU care:Look at the patient in total and look at the patient’s ulcer(s)

Pressure ulcer care is multidisciplinary care

-----------------------------------------------------------------------

Adequate and total wound care:

Local woundmanagement: - clean and debride the wound:

- cover and protect the wound:

Support the host: - identify and treat cause of wound; - optimize disease management;

and: - optimize nutritional status!!(Kiy e.a. 1997)

PU / chronic wounds and malnutrition are often

associated with each other!

Back to … Malnutrition

Malnutrition is a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes adverse effects on tissue / body form (body shape, size and composition) and function, and clinical outcomes.

in this presentation we focus on UNDERNUTRITIONM.Elia, 2000

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Malnutrition = undernutrition

Clinical depletion

Undesired weight loss

Underweight

PCM / PEM (=Protein Calorie / Energy Malnutrition)

Malnutrition of multiple nutrients

…………..

Disease-related malnutrition

Malnutrition;…causes

< intake of nutrients

intake does not meet nutritional needs

> loss of nutrients

Adverse consequences of malnutrition..

Impaired physical function:- impaired immune function

- reduced muscle strength and fatigue

- inactivity

- impaired wound healing- increased comorbidity

- increased mortality

Impaired psychosocial function:

- apathy, depression

- impaired social interactions

- reduced QoL

many authors

PU and Malnutrition much more often occur in frail elderly and geriatric patients..!!

‘Frailty is a dynamic state on a continuum in which an individual has deficits in one or

more domains of human functioning (physical, psychological, social), which,

under the influence of a diversity of variables, increase the risk of adverse outcomes’….

Gobbens, Luijkx, Wijnen, Schols 2008

Frailty may affect autonomy....

Frailty in fact may lead to complete disability, making a

person dependent on others…

The geriatric profile

Multimorbidity

Considerable amount of disabilities and handicaps

Polypharmacy

Difficult cure and care decisions

Problems w.r.t. living, welfare and the provision of care

Problems w.r.t. the organization of care: multiple care providers and professionals with secondary collaboration, communication, coordination and continuity problems

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Malnutrition

a common problem in patients with an acute or chronic disease…and with co-morbidity, such as PU!

Malnutrition: prevalence…? Home care: 10 - 25%

Nursing home: 25 - 40%

Hospital: 25 - 60%

Todorovic V, 2002; Edington J, 1996/1997; Thomas DR et al, 1991; LPZ 2008 and others

In chronic (institutional) care mostly:

chronic nutritional depletion:

- light catabolic state;(long lasting)

- after primary loss of glycogen, mainlyloss of fat

Loss of body weight is a clear sign of malnutrition!

Weight loss is independent risk factor for:– Morbidity– Complications, such as PU and chronic wounds– Institutionalisation– Mortality

Sauerwein HP, 1999; Breslow R, 1991

EVIDENCE: EPIDEMIOLOGY!

Protein-calorie malnutrition:

- > risk to develop pressure sores

- > risk to develop chronic wounds

- < rate of wound healing

chronic wounds and malnutrition are associated with a poor outcome; separately and additionally!!

Berlowitz et al 1989; Breslow 1991; EK et al 1991; Allman RM et al, 1995; Thomas 1997; Mathus-Vliegen EMH 2001 Stratton et al 2005

When is a wound (specific) nutritional supplement of value for the PU (prone) patient?

1. If it prevents the occurence of PU

2. If it promotes healing of established PU

and

3. If it contributes in improving nutritional status;

4. If it contributes to an improved functional ability and/or enhanced quality of life.

These outcome variables have to be assessed in scientific

research as well as in daily practice!

Evidence shows nutrition support can prevent pressure ulcers in at risk groups:

‘Nutritional support, particularly high protein oral nutritional supplements, can significantly reduce the risk of developing pressure ulcers (by 25%)’

(Stratton et al 2005)

Nutrition may also be vital to enable the healing of pressure ulcers:

‘Our systematic review suggests that the healing of pressure ulcers may be improved with nutritional support’

(Stratton et al 2005)

Prevention and treatment of pressure ulcers:

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Experience: adequate nutritional intake in patients with PU..?

0

20

40

60

80

100

% R

esp

on

den

ts

Adequate intake?

Yes

No

?

Schols JMGA et al, 2000

Daily practice: nutritional attention..: when?

Schols JMGA et al, 20000

20

40

60

80

100

%R

esp

on

den

ts

Stage PU

Stage I Stage II Stage III Stage IV

Nutrition in Prevention Guidelines

GENERAL RECOMMENDATIONS

1.Screen and assess nutritional status for every individual at risk of pressure ulcers in each health care setting. (Strength of Evidence = C)

1.1 Use a valid, reliable and practical tool for nutritional screening that is quick and easy to use and acceptable to both the individual and health care worker. (Strength of Evidence = C)

1.2 Have a nutritional screening policy in place in all health caresettings, along with recommended frequency of screening for implementation.

Nutrition in Prevention GuidelinesGENERAL RECOMMENDATIONS

2. Refer each individual with nutritional risk and pressure ulcer risk to a registered dietician and also, if needed to a multidisciplinary nutritional team including a registered dietician, a nurse specialized in nutrition, physician, speech language therapist, occupational therapist and/or dentist. (Strength of Evidence = C)

2.1 Provide nutritional support to each individual with nutritional risk and pressure ulcer risk, following the nutritional cycle. This should include:

- Nutritional assessment

- Estimation of nutritional requirements

- Comparison of nutrient intake with estimated requirements

- Provide appropriate nutrition intervention, based on appropriate feeding route

- Monitoring and evaluation of nutritional outcome, with reassessment of nutritional status at frequent intervals while an individual is at risk. (Strength of Evidence = C)

2.2 Follow relevant and evidence based guidelines on enteral nutrition and hydration for individuals at risk of pressure ulcers, who show nutritional risks or nutritional problems. (Strength of Evidence = C)

2.3 Offer each individual with nutritional risk and pressure ulcer risk a minimum of 30-35 kcal per kg body weight per day, with 1.25 -1.5 g/kg/day protein and 1ml of fluid intake per kcal per day. (Strength of Evidence = C)

Nutrition in Prevention Guidelines

SPECIFIC RECOMMENDATIONS

Offer high protein mixed oral nutritional supplements and/or tube feeding, in addition to the usual diet, to individuals with nutritional risk and pressure ulcer risk because of acute or chronic diseases, or following a surgical intervention. (Strength of Evidence = B.)

– Administer oral nutritional supplements (ONS) and/or tube feeding (TF) in between the regular meals, to avoid reduction of normal food and fluid intake during regular mealtimes. (Strength of Evidence = C.)

Nutrition in Treatment Guidelines GENERAL RECOMMENDATIONS

4. Provide and encourage adequate daily fluid intake for hydration. (Strength of Evidence = C)

4.1 Monitor individuals for signs and symptoms of dehydration: changes in weight, skin turgor, urine output,

elevated serum sodium or calculated serum osmolality. (Strength of Evidence = C)

4.2 Provide additional fluid for individuals with dehydration, elevated temperature, vomiting, profuse sweating, diarrhea or heavily draining wounds. (Strength of Evidence = C)

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Nutrition in Treatment Guidelines GENERAL RECOMMENDATIONS

5. Provide adequate vitamins and minerals. (Strength of Evidence = B)

5.1 Encourage consumption of a balanced diet which includes good sources of vitamins and minerals. (Strength of Evidence = B)

5.2 Offer vitamin and mineral supplements when dietary intake is poor or deficiencies are confirmed or

suspected. (Strength of Evidence = B)

Outcome of nutritional intervention

Increased weight / improved nutritional status

Improved functional ability and/or enhanced quality of life

Reduced incidence of new pressure ulcers

Healing of established pressure ulcers

PU-patients deserve integral treatment

So, besides pressure and shear relief, we have to take care of adequate skin care and in case of established ulcers of adequate woundbed preparation with secondary use of adequate wounddressings to promote woundhealing; and last but not least we have to give the patient adequate nutritional attention.

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