Idea Transcript
Nutrition and Wound Healing… The Connection
Nutrition in Wound Healing
Conditions Leading to Malnutrition • Catabolic illness: Trauma, surgery, sepsis, etc • Involuntary weight loss for any reason • Chronic illness: Diabetes mellitus, cancer, renal failure • Chronic wounds • Increased nutritional losses: Enteral fistulas • Intestinal diseases impairing absorption • Absent or impaired dentition • Impaired access to adequate food
Pre-wounded & Post-wounded States and Malnutrition • Preoperative illness with decreased po intake decreases collagen synthesis, even if patient not chronically malnourished • Brief intervention, either enterally or parenterally, can reverse this affect on collagen
• Majority of human evidence in area of pressure ulcers • Stage of pressure ulcer impacted by degree of malnutrition • Prevention of malnutrition = risk reduction for pressure ulcer formation • Determination of nutritional status is multifactorial process
Decreased Caloric Intake • Effects in rodents of decreased caloric intake of 50% – Decreased collagen synthesis – Decreased matrix & GAG deposition – Decreased granulation tissue formation
“The metabolic response to injury and stress is different from that of starvation…. “
Starvation Response • Generalized decrease in metabolic rate • First 18-24 hours glycogen stores are exhausted • Gluconeogenesis utilizes amino acids as the primary substrate
Starvation Adaptation • Human preservation instinct of lean body mass and muscle protein • This built-in instinct causes a drop in amino acid demand • Decreasing protein turnover, thus preserving lean body mass
Definition of Malnutrition A consensus statement by the Academy of Nutrition and Dietetics (AND) and the American Society of Parenteral and Enteral Nutrition (ASPEN) published in May 2012 defines malnutrition as the presence of 2 or more of the following characteristics • Insufficient energy intake • Weight loss • Loss of muscle mass • Loss of subcutaneous fat • Localized or generalized fluid • Decreased functional status
Fatty Acids in Starvation • Increased mobilization of fatty acids • Ketone bodies from fatty acids are used to provide 70% of the body’s energy needs • In starvation, the brain, which normally uses glucose, can utilize ketone bodies • This causes preservation of muscle
Stress Response • Follows an injury or severe stress such as sepsis • Characterized by: – Decreased systemic vascular resistance (lower blood pressure) – Elevated cardiac output – Fever – Hyperglycemia – Use of lean body mass, ie, muscle!!
How Does Malnutrition Impact Patients? • Increases morbidity and mortality • Impairs wound healing • Increases risk of pressure ulcer (PrU) development • Increases length of stay (LOS) • Compromises the immune status of patients • Increases risk of infection • Increases risk of falls • Higher treatment costs • Muscle wasting and functional loss • Higher readmission rates
Malnutrition, Lean Body Mass, and Wounds • Malnutrition is correlated with an approximate 4-fold higher risk of developing a PrU • Loss of lean body mass (LBM) is correlated with impaired wound healing • During bed rest, loss of LBM accelerates • 10% loss of LBM results in immune suppression and é risk of infection • Loss of ≥15% to 20% total LBM will impair wound healing
Why not assume every patient is malnourished? • Cost of supplementation • Some forms are invasive, such as TPN • Hyperglycemia seen with excessive supplementation • Overfeeding causes immune suppression
• Loss of ≥30% leads to development of spontaneous wounds and PrUs and lack of wound healing
Types of Malnutrition Marasmus
Kwashiorkor
Current Degrees of Malnutrition • Mild malnutrition: Difficult to differentiate from normal nutrition – No identifying criteria developed at this time
• Moderate or non-severe malnutrition • Severe malnutrition
• Both of these diagnoses are associated with the ICD-9 clinical modification codes and describe statuses that do not apply to patients seen by acute and chronic care clinicians in developed countries • AND and ASPEN are collaborating with the National Center for Health Statistics ICD Coordination and Maintenance Committee regarding revisions to current malnutrition code descriptions
• Diagnosis of malnutrition increases reimbursement for medical care • Patient with high body mass index (BMI) can also be diagnosed with malnutrition
Malnutrition References
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Nutritional Services; Catholic Health – Buffalo, NY 2015
Bistrain BR, Blackburn GL, Hallowell E, et al. Protein status of general surgical patients. JAMA. 1974;230:858. Haydock DA, Hill GL. Impaired wound healing in surgical patients with varying degrees of malnutrition. JPEN J Parenter Enteral Nutr. 1986;10(6):550-554. Windsor JA, Knight GS, Hill GL. Wound healing response in surgical patients: recent food intake is more important than nutritional status. Br J Surg. 1988;75(2):135-137. Curtas S, et al. Evaluation of nutritional status. Nursing Clinics of North America. 1989;2(2):301-311. The Academy of Nutrition and Dietetics. Malnutrition Coding. Available at Nutrition Care Manual Web site. Accessed November 9, 2016. Tappenden KA, et al. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. JPEN. June 4, 2013.
Morbid Obesity and Wound Healing • Protein-sparing diets common • High carb/sugar and low protein diets common among obese • Obese more likely to experience wound healing complications • Increase in post-op wound infection, dehiscence and seromas • Decreased vascular supply to adipose lobules and adipocytes
Nutritional Assessment Tools • Weight – Ideal body weight (IBW), usual body weight (UBW), and a comparison
• Food histories/diet recalls • Nutrition-focused physical assessment (NFPA) – Includes observation of muscle wasting, subcutaneous fat loss, fluid accumulation, and/or hand-grip strength
• Visceral proteins are a better indicator of morbidity and mortality than nutritional status – Significantly affected by inflammation
Joint Commission and Nutritional Assessment Who should be screened? Everybody! • The Joint Commission requires screening or assessment to identify patients who are at moderate or high risk for malnutrition (PE.1.3) • The Joint Commission also requires that interventional nutrition be monitored for effectiveness and appropriateness (TX.4.5)
Validated Nutritional Assessment Tools • Malnutrition Universal Screening Tool (MUST)
– Validated tool especially for hospital use
• Mini Nutritional Assessment
– Validated for older adults in community and long term care settings with or at risk for pressure ulcers
http://www.mna-elderly.com/. Accessed 11/12/2015. http://www.bapen.org.uk/pdfs/must/must_full.pdf. Accessed 11/12/2015.
The NPUAP and Nutritional Screening 1) Screen each individual at risk of or with a pressure ulcer: – At admission to a healthcare setting – With each significant change of clinical condition and/or – When progress toward pressure ulcer closure is not observed
2) Use a valid and reliable nutritional screening tool to determine nutritional risk 3) Refer those at risk of malnutrition or with pressure ulcer to Registered Dietitian or nutrition team for comprehensive nutrition assessment
Malnutrition
Universal Screening Tool Validated tool especially for hospital use
Ideal Body Weight (IBW)
Mini Nutritional Assessment Validated for older adults in community and LTC Settings with or at risk for pressure ulcers
• A weight that is believed to be maximally healthful for a person, based chiefly on height but modified by factors such as gender, age, build, and degree of muscular development. • Male: 106 lbs. for first 5 ft. plus 6 lbs. for each additional inch • Female: 100 lbs. for first 5 ft. plus 5 lbs. for each additional inch • Not useful for determination of nutritional status at given point in time
% Ideal weight
=
Actual weight x 100 Usual body weight
Usual Body Weight (UBW)
Total Body Weight (TBW)
• Body weight value used to compare a person’s current weight with his or her own baseline weight • The UBW may be a more realistic goal than the IBW for most individuals • Percentage deviation (loss) from UBW is most sensitive tool for nutrition assessment based on weight
• Measures 2 separate components – Lean weight: Muscles, bone, tendons, ligaments, and normal body water – Fat weight: Typically more in women • This measurement does not allow for excess water or for rapid fluid shift (eg, hemodialysis losses, resuscitation fluids in burns and trauma patients) • Need to check daily or every clinic visit in the outpatient setting • Look at overall trends over time
Lean Body Mass • Theoretically can be monitored using current body composition technologies – Total body potassium counting (K-counter) – Dual x-ray absorptiometry (DEXA) – Bioimpedance analysis (BIA)
• Not used on routine clinic basis
Nutrition-Focused Physical Findings • Body fat: Loss of subcutaneous fat in orbitals, triceps, overlying ribs • Muscle mass: Loss of muscle as noted by wasting of temples, clavicles, shoulders, interosseous muscles, scapula, thigh, calf • Fluid accumulation: Clinician evaluates generalized or localized fluid accumulation evident on examination – Weight loss can be masked by edema – Weight gain may be observed
• Reduced hand-grip strength in comparison to normative standards supplied by device manufacturer
Questionnaires • Good for identifying certain medical conditions that are prone to malnutrition • No one “best” survey or questionnaires • Some times must be “administered” if patients can not read
Indirect Calorimetry Assessment • Utility of IDC as a single measurement is controversial • Need to use multiple measurements and the trends in these measurements • Twice-weekly measurements allow for correlation with laboratory measurements, with appropriate adjustments of nutritional support
Liusuwan RA, et al. The respiratory quotient has little value in evaluating the state of feeding in burn patients. J Burn Care Res. 2008;29:655.
Laboratory Assessment of Nutritional Therapy • Glucose (optimal control