Nutr in Wounds

•

Nutrition Goals

•

•General goals:

–Control catabolism

–Meet macronutrient and micronutrient needs

–Increase anabolic stimulation
to preserve lean tissues

–Avoid replacement of
lost lean tissues with
fat tissues

–In patients with diabetes,
assure blood glucose
control

After assessment, we can then establish goals for a nutrition care plan. One of the most immediate concerns is to control the catabolism that occurs with especially severe and non-healing wounds. One of the ways to control catabolism is to assure that there is a balance of nutrients provided. Nutrients that are typically depleted during chronic and other wounds should be emphasized. In addition to meeting nutritional needs, efforts to improve anabolic stimulation through exercise and, in some cases, anabolic hormone therapies has also shown promising results.

In all patients, but especially in elderly patients, it is important to balance nutritional intake so that sarcopenia (loss of muscle tissue) is not replaced primarily with fat tissues.

Because injuries generally lead to higher levels of blood glucose and lower levels of anabolic hormones, including insulin, special attention should be paid to controlling blood sugar in patients with diabetes.

•Macronutrients:

–Fluids

•Increased to 30-40 ml/kg/d

–Calories

•Increased to 30-40+ kcal/kg/d

–Protein

•Increased from 0.8 g/kg/d to up to 3.0 g/kg/d

To determine nutrient needs, we can start with a baseline of what a person without a wound might need to maintain nutritional status and health. Fluid requirements are based on fluid turnover. In the case of wounds, increases to 30-40 milliliters per kilogram per day can be seen due to the additional losses through heat generated and exudate from the wounds.

In general a healthy person will need around 25 calories per kilogram per day. An elderly person might require less, or around 20 calories per kilogram per day. When a person has a wound, energy requirement may increase 30-50% to around 30-40 calories per kilogram per day. While patients who are malnourished at baseline may require some additional calories to both support wound healing and restore nutritional status, caution should be used in increasing calorie intake to prevent complications of overfeeding. In the case of obesity, it may be possible to maintain an adequate energy intake at a lower level of around 20-25 calories per kilogram per day. Carbohydrates remain the primary source of energy in wound healing situations, providing 55-60% of energy needs. About 20-25% of calories are recommended as fat or below around 2 grams per kilogram per day.

Protein requirements can double during injury and infection. In general, protein requirements during chronic wounds and to correct protein malnutrition could be considered around 1.5 grams per kilogram per day, which is about twice the recommended intake for healthy people and, as it happens, about the level of intake in the average American diet. Patients who have difficulty in getting adequate protein may require education on which foods emphasize dietary protein, high quality protein sources, and even supplemental protein, in some cases. An emphasis is placed on protein in dietary planning for the elderly, unless contraindicated by renal disease. The reason for this is that if excessive calories are consumed, protein calories can be utilized to maintain lean tissues and reduce the chance for the development of sarcopenia (or literally the loss of muscle tissue) and while gaining too much in the fat compartment. Dietary protein intake should account for about 20-25% of calories.

Specific Nutrient Recommendations

•Micronutrients:

–Vitamins

•Vitamin A

•Vitamin C

•Vitamin E

Micronutrients are important for cellular function. Deficiencies can reduce the healing potential for wounds, and may exacerbate the inflammatory process and continued catabolism. Vitamins most noted in wound healing include vitamins A, C, and E. Vitamin A is essential to stimulate initiation of the wound healing process and building of epithelial layers and collagen. Vitamin A is also helpful to maintain immune function and is involved in protein anabolism.

Vitamin C is essential to collagen synthesis. It is helpful to reduce the damage to tissues by acting as an antioxidant, supporting immune function as well.

Vitamin E acts as an antioxidant, helping to reduce tissue damage and also helping to maintain cell membrane integrity.