Nutrition Guidelines for Pressure Ulcer Management

1. Nutrition Guidelines for Pressure Ulcer Management 1/4/07

2. Braden > 18 No Pressure Ulcer orNon-Healing Wound • Monitor intake and weight • Consult dietitian if: • Usual criteria on Admission Database • Intake consistently less than 75% • Nausea, vomiting, diarrhea • Metabolically stressed state - trauma, fever • Significant weight loss (non fluid related): • 1% in 1 week • 5% in 1 month • 7.5% in 3 months • 10% in 6 months

3. Recommended RD Actions Braden> 18 without Pressure Ulcer with↓appetite, weight loss,  needs,  loss via V & D Complete nutrition assessment Based on findings: Request pre-albumin Add oral supplements Add between meal snacks Assistance, reminders, encouragement at mealtime 3 Day Calorie Count Based on response to above consider: Tube feeding Parenteral nutrition

4. Braden < 18 Without Pressure Ulcer/Non Healing WoundWith adequate nutrition intake Nutrition Goals: • Maintain current intake of nutrition • Achieve and maintain desirable weight • Routine Follow Up: • Visual assessment of skin • Back of head • Elbows • Heals • Back side • Assessment of: • Weight • Intake • Pre-albumin • Changes in condition

5. Braden < 18 Without pressure ulcer or non healing wound; With inadequate hydration, protein &/or weight loss Nutrition Goal: Protein: 1.2g pro/kg/d Calories: 25 – 30 kcals/kg/d 29 – 33 kcals/kg/d Para 24 – 27 kcals/kg/d Quad Use ABW subtract 5 – 10 kcals/kg/d for Obesity Fluid: • 30 ml/kg; min of 1500 ml/d unless contraindicated • SCI: 35 ml/kg; min 2500 ml/d unless contraindicated • Add 10 – 15 ml/kg for air fluidized beds

6. Recommended RD Actions ContinuedBraden < 18 Without pressure ulcer or non healing wound; With inadequate hydration, protein &/or weight loss • Complete nutrition assessment • First meet fluid needs • Supplement with whey protein powder or use whey based tube feeding • e.g.Propass 6 gm/pkt • If BMI < 20 change diet to high cal/high protein • Add therapeutic multi-vit/min supplement

7. Recommended RD Actions ContBraden < 18 Without pressure ulcer or non healing wound; With inadequate hydration, protein &/or weight loss • Follow up weekly: • Visual assessment • Assessment of wt, intake, pre-albumin, medical condition • Correct source of poor intake if able • Food preferences • Constipation • Illness depression • Pain • Medication causing poor appetite • Consider glutamine: 10 g/d • Evaluate need for anabolic agent and/or nutrition support

8. Stage 1 & 2 Pressure UlcersWithout: heavy exudate, VAC therapy, poor appetite, diarrhea, weight loss, Alb < 3.5 or PAB < 15 Nutrition Goal: Protein: 1.2 – 1.5g pro/kg/d Calories: 25 – 30 kcal/kg/d 29 - 33 kcals/kg/d Para 24 - 27 kcals/kg/d Quad Use ABW & subtract 5-10 kcals/kg/d for obese Fluid: • 30 ml/kg; min of 1500 ml/d unless contraindicated • SCI: 35 ml/kg; min 2500 ml/d unless contraindicated • Add 10 – 15 ml/kg for air fluidized beds (Matrix Matress Replacement or Kinair)

9. Recommended RD Actions:Stage 1 & 2 Pressure Ulcers: Without: Heavy exudate, VAC therapy, poor appetite, diarrhea, wt loss, Alb < 3.5 or PAB < 15 • Complete nutrition assessment • First meet fluid needs • 10 – 15 gm/d whey protein • 7 – 15 gm/d arginine • Therapeutic multi vitamin min supplement • 25 mg zinc along with 2 mg of Cu for 2 weeks or less • Follow up weekly

10. Stage 1 & 2 Pressure UlcersWith: heavy exudate, VAC therapy, poor appetite, diarrhea, weight loss, Alb < 3.5 and/or PAB < 15 Nutrition Goal: Protein: 1.5 – 2.5 gm pro/kg/d Calories: 30 – 35 kcal/kg/d 33 - 35 kcals/kg/d Para 27 - 30 kcals/kg/d Quad Use ABW & subtract 5-10 kcals/kg/d for obese Fluid: 35 ml/kg; min of 2000 ml/d unless contraindicated SCI: 35 ml/kg; min 2500 ml/d unless contraindicated Add 10 – 15 ml/kg for air fluidized beds (Matrix Mattress or Kinair bed)

11. Recommended RD Actions:Stage 1 & 2 Pressure UlcersWith: heavy exudate, VAC therapy, poor appetite, diarrhea, weight loss, Alb < 3.5 and/or PAB < 15 • Complete Nutrition Assessment • First meet fluid needs • 10 – 15 gm/d whey protein • 10 – 20 gm/d arginine • Therapeutic multi vitamin min supplement • 25 mg zinc along with 2 mg of Cu daily for 4-6 weeks or less • Check Oxandrolone guidelines for appropriateness if weight loss and skin breakdown present (See Oxandrolone guidelines) • If Tube Fed, use peptide based formula; avoid formulas high in simple CHO • Follow up at moderate to high risk (1-2 times/wk)

12. Stage 3 & 4 Pressure UlcerNon Healing Wound Nutrition Goal Protein: 1.5 – 2.0 gm/pro/kg/d Calories: 30 - 35 kcals/kg/d (35 – 40 if heavy exudate) 33-35 kcals/kg/d para 27 – 30 kcals/kg/d quad Fluid: 35 ml/kg;min of 2000 ml/day unless contraindicated SCI: 35-40 ml/kg;min 2500-3000 ml/d unless contraindicated Add 10 – 15 ml/kg for air fluidized beds (Matrix Mattress or Kinair bed apply)

13. Recommended RD Actions:Stage 3 & 4 Pressure Ulcer/Non Healing Wound • Complete Nutrition Assessment • First meet fluid needs • 10 – 15 gm/d whey protein • 10 – 20 gm/d arginine • Therapeutic multi vitamin min supplement • 25 mg zinc along with 2 mg of Cu daily for 4-6 weeks • Check Oxandrolone guidelines for appropriateness if weight loss and skin breakdown present (See Oxandrolone guidelines) • If Tube Fed, use peptide based formula; with MCTs; avoid formulas high in simple CHO • RD follow at moderate to high risk (1- 3 times/wk)

14. Actions/Benefits Relative low cost Anti catabolic Increased protein synthesis Marked return of lean mass in conjunction with optimum nutrition vs nutrition alone Wt gain approximately 75% lean body tissue Acts on cell androgenic receptors Cleared by kidneys, avoiding hepatotoxicity Anabolic effect is dose dependent Well tolerated for long-term use Contraindications/Side Effects Stimulation of androgen-sensitive tumors, mainly prostate CA Known liver disease or LFTs greater than twice the upper limit of normal Oral anticoagulation therapy e.g. warfarin Pregnancy Breast Cancer (male or female; hypercalcemic type) Prostate CA Nephrosis Hypocalcemia Uncontrolled diabetes Oxandrolone Action: amino acids driven into protein synthesis pathway; catabolic activity is decreased

15. Dosing of Oxandrolone • Usual Dose: 10 mg twice daily • Renal insufficiency: 5 mg twice daily • Strive for adequate protein intake first

16. Arginine: Wound Healing (via IGF 1) Required for collagen synthesis (precursor to polyamines) Increased in collagen deposition in wound bed with 15g of arg/d Average dietary intake 7.5g arg/day Increased blood flow Nitric Oxide Pathway NO levels decreased in DM Glutamine: Nitrogen Shuttle Regulates protein turnover Stores depleted at 10 – 15% loss of lean body mass Immunity Preferred fuel source for lymphocytes & enterocytes N-Acetyl Cysteine + Glutamine = Glutathione which leads to decreased oxidative stress GI Function & Immunity Restores gut integrity & brush boarder which improves absorption & appetite (20 g gln/d) Precursor for nucleotides Helps maintain Acid base balance Ammonia production Conditionally Essential Amino Acids

17. Conclusions: • These recommendations are from best practice organizations and the dietetics profession. • Several have not been tried here at HCMC and are worthy of trial. • Our challenge is to implement these guidelines and evaluate effectiveness in the population at HCMC.