Pressure Ulcer Management: Tips from the Field Nutritional Gems

1. Pressure Ulcer Management: Tips from the FieldNutritional Gems Evelyn Phillips, MS, RD, LDN Clinical Nutrition Manager and Researcher JHS / Magee Rehabilitation Hospital Philadelphia., PA ephillips@mageerehab.org

3. Chronic/Acute illness: DM, CVD, RA, DJD, IBD, MS, ALS, GBS, Obesity, Metabolic Syndrome, Hyperthyroidism, CKD, ESRD, SCI Prolonged steroids Aging Burns, Trauma, Surgery Hyperglycemia Immobility Infections, Fever, Sepsis Long-bone fractures Periodontal Disease Pressure Ulcers Inflammatory Conditions withNutritional ImplicationsSame as Risks for Pressure Ulcers

4. Common risk factors for malnutrition as well as pressure ulcer formation or progression.Same as group for inflammatory conditions. Recent Metabolic Stress H/O pressure ulcers Advanced Age Poor nutritional status Underweight, Recent IWL, Obesity ? ALB & PAB Poor Glycemic Control Compromised Intake Dehydration Malabsorption Bowel Ds / Diarrhea Alb< 3.0; Anasarca Ostomies / Fistulas Comorbidities DM, CKD, CVD, COPD Functional dependence Immobility Poor circulation, PVD Incontinence Poor skin condition

6. Inflammation�Malnutrition�WoundsBiologic Markers of Inflammation ? CRP with ? ALB ? PAB ? CRP in ICU ? Organ failure, poor outcomes and death1 ?PAB Inflammatory Marker2 < 13.7 +/- 3.8 mg/dl = ? Risk for pressure ulcer ? Blood glucose3 ALB (normal hydration) < 2.5 = ? Diarrhea4 < 3.0 = Stagnant wound with VAC5 < 3.5 = Poor outcomes & ? Risk for pressure ulcer6

7. Barriers We See at Magee Poor or Inappropriate Oral Intake Illness/Meds / Pain / Depressed / Dysphagia High calorie / sugar supplements Juice Abuse / Excessive intake Megace = Excessive Appetite and� Lowers testosterone Increases water & fat weight Hyperglycemia Increased risk for thrombosis

8. Barriers We See at Magee Inappropriate Tube Feedings Malnutrition malabsorption treated w/ Fiber TF/Dehydration � Impactions Standard TF = Intact protein, ?N6/?MCT �Tolerating TF w/diarrhea� � Rectal tubes Delay or no tube placed Aspiration Risk + Bolus TF/Diarrhea Excessive Calories

9. 35 year old Paraplegic with necrosis of the Prostate gland and multiple recurrent ischial, perineal, and sacral wounds.

10. Pressure Ulcer as Marker of Inflammation & Malnutrition?

11. Inflammatory Response Increase Catecholamine Cortisol Decrease Insulin Testosterone Altered growth hormone

13. Intervene Early (<36hrs) Control Inflammation Preserve Gut Integrity Breaking the �NPO mindset� Lack of enteral stimulation results in atrophy of Gut Associated Lymph Tissue (GALT) The Gut then becomes pro-inflammatory by up-regulating IL-2, IL-5, and TNF-b. These cytokines travel to the respiratory system via the lymphatic system � contributing to respiratory distress (EE Moore Trauma 1994;37-881)

14. Inflammation�Malnutrition�WoundsEarly Intervention Meet at least 65% of needs within 3-4 days Include feeding tube placement in trauma/surgical/critical care protocols Provide enteral stimulus w/ TPN as able Leave the tube in until adequate & consistent oral intake for solids & liquids is demonstrated Use for partial hs TF, fluids, supplements, meds Allow secondary facility to remove, note placement date

15. Inflammation�Malnutrition�WoundsEarly Intervention Be mindful of time on NPO/Clear Liquids Include protein supplement w/clear liquid diet Monitor intake. If indicated, need to be proactive in PEG placement to help prevent skin breakdown. Ensure adequate p.o. fluids or feeding tube flushes before stopping IVF.

16. Nutritional Gems: The Pearls of Intervention

17. Treating Inflammation as Part of Nutrition Management of Pressure Ulcers

18. The Pearls of Intervention Determine Your Starting Point Co morbidities: Tally inflammatory conditions present Meds that ? insulin resistance, steroids, megestrol acetate Significant Weight Loss, Under or Over weight? ? 1-2% in 1 week; 5% in 30 days; 7.5% in 3 months; 10% in 6 months BMI < 18.5 or >30 (>27 in ICU) Poor intake > 7 days, constipation � BOWEL ROUTINE Physical S/S of malnutrition, dehydration and deficiencies Diarrhea > 3 days Labs: ?BS, ?CRP, ?PAB. ALB < 3.5, 3.0, 2.5 mg/dL?

19. The Pearls of InterventionWound Status as Inflammatory Marker Non-Healing Unstageable, DTI or Stage 3 & 4 Heavy exudate Pale wound bed In Clinical Practice Correlates with ? CRP anorexia, ? taste acuity, & diarrhea For majority of patients, early intervention is not possible. We need For majority of patients, early intervention is not possible. We need

20. Loss of Gut Integrity � Outside View

21. The Pearls of InterventionPrioritizing Nutrition Interventions Putting protein and calories in their place Hydration Glycemic control Protein Calories

22. The Pearls of Intervention Fluids First! Do Not increase protein w/o adequate fluids 1st Fluids as Med Pass, even without meds Educate patient/family/visitors to push fluids OT to maximize independence with drinking Self flushing TF pumps � more than 25 mLs/hr PEG tube for fluids only? Monitor for when IVFs are discontinued, adjust other fluids prn.

23. The Pearls of InterventionFluids & Enteral Tube Feedings How much fluid comes from solid foods? Typical enteral formula water content 1.0 cal/mL = 80% 1.5 cal/mL = 75% 6� 150 lb male + draining Stage IV pressure ulcer 1.5 to 2.0g Pro/kg = 100 -135g 35 ml or kcal/kg = 2400 mLs & kcals 1.0/1.5 = 1900/1200 mLs from TF 1.0/1.5 = 500/1200 mLs needed from flushes

24. The Pearls of Intervention Fluids First! Additional protein is not always appropriate If unable to correct dehydration, can not increase protein -- wound healing may not be the goal. Monitor hydration status with additional protein Serum values, urine osmolality, oral cavity Check output � N/V/D, wound drainage, fistulas, ostomies, sweating, hyperglycemia, Diabetes Insipidus, medications�.

25. Case Study: 57y.o. Female. CHF s/p VDRF, trach, pacemaker, PEG, CRI, & Stage IV coccygeal ulcer to rehab for deconditioning PMH: Nonischemic cardiomyopathy, DM2, & CKD. Nutrition orders per transfer chart: Cardiac diet w/2000 mls fluid restriction Renal TF @ 50mls/hr X 12hrs = 42g Pro / 1200 cals 3 scoops of protein powder TID = 45g Pro / 270 cals Canned 1.5 supplement TID = 39g Pro / 1080 cals Arg/Gln /HMB supplement TID = 65 N2 eqv / 235 cals/ 810mg K / 285mg Phos 3+g Pro/kg & 64 kcals/kg

26. The Pearls of InterventionGlycemic Control In practice, not all patients benefit from high calorie interventions May need to underfeed at first, adjust meds, then increase calories as able / as appropriate Hyperglycemia & Overfeeding = Pro-Inflammatory Continued loss of LBM Dehydration Impaired immune function, Infection risk Poor wound healing

27. The Pearls of Intervention Glycemic Control Tips Consider sugar free or low carbohydrate products even for non-diabetics Consider products w/ higher % of fat as MCT MCT: readily absorbed, maintain caloric density with less CHO and less pro- inflammatory omega 6 fat Dysphagia Offer variety of thickened liquids, limit juice i.e., water, milk, sugar free/decaf beverages

28. Case Study JR 34 yo Portuguese male PMH: � C4 Asia A Quadriplegia s/p fall 2/15 S/P multiple C-spine surgeries S/P Trach and PEG 2/15 Complications: Hypotension; DVT; PE; VDRF; Esophagealcutaneous fistula s/p multiple repairs, Repeated aspiration pneumonia; Line infections; and 4 pressure ulcers � Stages 2-3.

29. Case Study JR 4 Pressure Ulcers Two Stage 2 Sacral, min drainage Stage 3 Sacral, moderate drainage Stage 3 intergluteal with significant drainage.

30. Case Study JR Review of Transfer Nutrition RX NPO with early start of standard high protein TF @ 55mls ATC = 35kcals/kg and 1.8gpro/kg. TF advanced once wound care was addressed to 70mls/hr providing 50 kcal/kg; 2.8 g/pro kg PT noted to have episodes of N/V/D PAB trending downward despite or due to (?) advancement in TF rate

31. Case Study JR Weight Assessment UBW: 158# Admit Wt: 110# IBW SCI: 139-144# +/-10% % Loss ~30% 79% of IBW for SCI Intervention TF = 27 kcal/kg and 2.0 g/ kg protein + 15 g Arg + 20g Gln + 1g Vit C + 35mg Zn Oxandrolone 10 mg bid Flushes 250 ml q 4 hrs (Total fluid = 45mls/kg)

32. Case JR: Weight & Laboratory Trends

33. The Pearls of InterventionFats and Inflammation Medium Chain Triglycerides �MCT� Neutral Omega 6 Fat (palm or coconut oil) More readily absorbed; better bowel tolerance Fatty acids Omega 3: Anti-inflammatory properties Omega 6: Primarily pro-inflammatory Ideal Ratio: O 6: O 3 = 3:1. US diet = 20:1 Most Products: Low O 3 & only 20% fat as MCT

34. 59 y.o. male s/p MVA: Tetraplegia, trach, PEG, colostomy, hyperglycemia and stage IV sacral pressure ulcer. PMH: HTN Acute care regimen NPO on 24hr TF 2200 kcals + 125g Pro Standard 1.5 cal/ml high fiber formula, <20% of fat as MCT 3 scoops of protein powder bid Our Regimen NPO, on 14hr TF 2200 kcals + 125g Pro plus arg & gln Elemental 1.5 cal/ml formula with protein as small peptides & 70% of fat as MCT 30mls liquid pro bid Arg/gln combo bid and 1 pack powdered MV

35. 59 y.o. male s/p MVA: Tetraplegia, trach, PEG, colostomy, hyperglycemia and stage IV sacral pressure ulcer. PMH: HTN Acute care regimen 40 units 70/30 bid SS start at BG of 130 = 80-86 units/day. Average BG for past 48 hours: 150, range of 60 to 225 Watery stools per colostomy Our Regimen 20 units NPH with start of TF at 6pm, 28 units of NPH by day 4. SS start at BG of 150. Average 3 day BG: 135, range of 97 to 165 Average BG day 4-7: 117, range of 90 to 130 Pasty stools per colostomy

36. The Pearls of Intervention Protein Adequate stores modulate inflammation Immune function, enzymes, cytokines, hormones 1.2-1.5g/kg/d, up to 2g/kg/d for large draining wounds High risk for dehydration with 2.5g/kg/d Need to reassess needs with weight changes Use IBW or estimated dry Wt if edema present Use upper range of IBW for obesity

37. The Pearls of Intervention Protein � Facilitate Absorption If Albumin is < 3.0 (diarrhea likely) Enteral Feeding Consider elemental TF with protein as small peptides A high fiber TF will not correct malabsorption diarrhea Consider: pre/probiotics, soluble fiber, banana flakes Oral Supplements Consider hydrolyzed liquid protein supplement Standard supplements may cause dumping with ALB < 2.5 Consider: pre/probiotics, soluble fiber, banana flakes or chips

38. Why Peptide Based Enteral Formula? To Facilitate Protein Absorption Inflammation suppresses protein synthesis Small peptides, < 50 amino acids, are absorbed directly � they do not rely on digestive enzymes (proteins) as do intact proteins & larger peptides. Improve N2 balance & visceral protein synthesis Improved visceral proteins help to modulate inflammation

39. The Pearls of InterventionMicronutrients � No Magic Bullet ALL are important, even the undiscovered ones Synergistic & Competitive Can not be studied individually & often act indirectly Modulators of inflammation Utilization increases during metabolic stress Lost in wound drainage, i.e. Zn is in 200+ MMPs Absorption/requirements influenced by: Age, sex, medications, activity, illness, diet, smoking, environmental and genetic factors

40. The Pearls of InterventionMicronutrients � No Magic Bullet �Supplement if deficiency is suspected or present� How is this to be determined? What about sub-clinical or prevention of deficiencies? Reasonable to give RDI Clinical Practice: Higher levels with heavily draining wounds for 2-4 weeks or less based on drainage/healing.

41. The Pearls of InterventionMicronutrients � No Magic Bullet Check your vitamin Standard MV contains only 6 micronutrients Liquid MV can still be inadequate Therapeutic MV may not breakdown, especially with ostomies, diarrhea, or impaired GI integrity Clinical Practice: Chewable or powder/dissolvable Therapeutic MV

42. Vitamin C Benefits may be direct or indirect Acts to decrease free radical damage at site of wound and reduces whole body stress Decreases edema � increase vascular density Improved pulmonary function � increased profusion The tolerable upper intake level in adults is 2000 mg/d.

43. �A nutrient that is usually produced in adequate amounts by endogenous synthesis but that is exogenously required under certain circumstances. Arginine, glutamine, cysteine, glycine, carnitine, and choline, are classified as conditionally essential nutrients.� The Role of Conditionally Essential Nutrients

44. The Pearls of InterventionArginine Conditionally essential in GI disease, TPN, growth, pregnancy, severe stress, trauma, protein deficiency & malnutrition Depletion impairs wound healing & results in decreased wound breaking strength. Adequate supplies rely on glutamine & proline availability to maintain positive nitrogen balance

45. Arginine as Modulator of InflammationSole Substrate for Nitric Oxide Increases wound & gut profusion. Improved healing of burn wounds, reducing the infection rate & hospital LOS with supplemental arginine. Impaired diabetic wound healing can be corrected with supplemented Arg which enhances wound NO synthesis. �Supplemental Arg (6g/day), is safe & effective in potentiating surgical angiogenesis in humans.� Ruel, 2008 Caution with septic patients

46. The Pearls of InterventionGlutamine as a Modulator of Inflammation In catabolic patients lack of Gln causes loss of gut integrity & decreases effectiveness of GALT. GLN regulates glutathione levels Powerful antioxidant for oxidative stress Aides in metabolism, protein synthesis, immune response & cytokine production Adequate selenium also needed

47. The Pearls of InterventionGlutamine Supplementation In critical illness: Decrease in the incidence of infections, LOS, reduced N2 loss & mortality rate. In surgical patients: Improved immunological parameters, Trophic effect on the intestinal mucosa, Decreased the intestinal permeability. �Immunodeficiency in critically ill surgical patients may in part be due to decreased gln levels.�

48. The Pearls of InterventionArginine & Glutamine Supplementation Arginine � caution with renal disease High nitrogen amino acid, increased fluid requirements Metabolism can elevate serum potassium Glutamine � caution in liver disease Metabolism increases ammonia production Adequate arginine supplies requires adequate glutamine, and both arginine and glutamine require adequate protein and micronutrients.

49. HMB �-hydroxy-�-methylbutyrate Metabolite of the indispensible amino acid Leucine. Rx amount: at least 38mg HMB/kg/d, Safe up to 6g/d Current healthcare product w/HMB, previously a �gym� product, purchased by medical nutrition company and marketed for wound healing. 20 studies to support it�s ability to increase LBM, alone or in combo with arg, gln, lysine, or BCAA. 7 studies that do not show benefit. Difference in outcomes attributed to variation in the level of resistant exercise

50. HMB and Wound Healing One study using 35 healthy, human volunteers 70 years or older showed increased collagen deposition with mixture of arg/gln/HMB vs placebo. Subcutaneous implantation of two small, sterile polytetrafluoroethylene tubes into the deltoid region under strict aseptic techniques.

51. 74 y.o. Central Cord Syndrome s/p FallPMH: DM2 Acute Care NPO on Standard high fiber formula TF stopped once cleared for p.o. diet �Questionable Stage 3 sacral ulcer� Acute Rehab Minimal p.o. intake Definite Stage 4 sacral wound � started on VAC TF 1L q HS = 1500cal/68gPro Oral: Arg/Gln/Vit cocktail BID. Supplemental protein added when TF discontinued Goals: BS WNL, Correction of edema, Wound Healing

52. Response to Intervention

53. Modulating Inflammation Associated with Non-Healing Pressure Ulcers � Not Nutrition for Wound Healing For majority of patients, early intervention is not possible. We need For majority of patients, early intervention is not possible. We need

54. Clinical Practice for Non-Healing Wounds �Cocktail� of arginine, glutamine, protein supplement and powdered therapeutic multivitamin & mineral. One-two servings a day based on weight Individual components can be added to TF regimen, then discontinued as appropriate. Arginine and glutamine are never given without a supplemental protein source. Not used with poor fluid intake, renal, or liver disease

55. Non-Healing Stage 2, 3 & 4 &/Unstageable Wounds /DTI + Inflammatory Trigger Protein/kg 1.5 to 2.0 g Kcals/kg 25 to 35, as able Arg 15g, max of 20-25g Gln 15-20g, max of 30g TF Peptide-Based Formula Step down to standard intervention in 2-4 wks, as able.

56. Guidelines for Estimating Needs for Wound Healing in SCI

57. Good tolerance: What to look for Close to normal stooling Rapid repletion of PAB Decreasing CRP Glycemic control Restoration of appetite/physical function as able Weight trending towards goal Correction of edema Wound healing/prevention Intervene early or expect slower recovery

58. Synergy

59. Questions and maybe some answers