Nutrition and Complicated Pressure Ulcers

by Osama Mitri, MD

Introduction

It is important that all patients with pressure ulcers or who are at risk for development of pressure ulcers be evaluated in regard to their nutritional status by means of:

1. Detailed history and physical exam.
   
2. Interview of family members and caregivers.
   
3. If appropriate, especially when patient has a stage 2 pressure ulcer or worse, laboratory evaluation to assess vitamin deficiency, albumin, and pre-albumin.
   
4. Meal intake assessment.
   
5. Calorie intake assessment.

Wound healing is a complex process. Energy and macronutrients such as proteins and certain vitamins are required.

Research Overview

Although no direct relationship is established, there is a relation between malnutrition and impaired oral intake and development of pressure ulcers.
However, the evidence to recommend enteral tube feeding to promote pressure ulcer healing is lacking.^{1, 4, 5, 6}

A systematic review of studies evaluating relations between enteral nutritional support and pressure ulcer prevention and treatment shows enteral nutritional support, particularly high protein supplements, can significantly reduce the risk of developing pressure ulcers (by 25%). Although studies suggest oral nutritional supplements and enteral tube feeding may improve healing of PU, further research to confirm this trend is required.¹

Another study evaluating tube feeding effect on pressure ulcer development in patients with a fracture of the hip concluded that “we were not able to show a significant decrease in development and severity of pressure sores, because the nasogastric tube for supplemental feeding was not well tolerated in this patient group”.²

A 2004 study in long-term care setting found that “A broad range of factors, including nutritional interventions, fluid orders, medications, and staffing patterns, are associated with prevention of PUs in long-term care residents. Research-based PU prevention protocols need to be developed that include these factors and target interventions for reducing risk factors”.³

Another review article noted the difficulty in making a decision regarding initiation of tube feeding “when considering nutritional support, oral supplementation should be weighed against tube feeding, as the associated morbidity of tube feeding, i.e., diarrhea, fecal incontinence, and restricted mobility being in themselves risk factors for pressure ulcers, might obscure the favorable effects of adequate nutrition”.⁴

Recommendations

General consensus recommends adequate oral intake of energy (30-35 kcal/kg) and protein (1.2 -1.5 g/kg) with provision of the recommended daily allowances of micronutrients and with correction of any nutrient deficiencies.⁴

Although there is no clear evidence to support it, many physicians recommend using protein and vitamin supplements.

A nutritional consult should be considered in the following situations:

1. Patients with stage 2 pressure ulcers or worse.
   
2. Patients with protein loosing enteropathy, nephropathy, or with liver disease.
   
3. Patients with unintentional significant weight loss, i.e. 10% of weight loss over 6 months or 5% of weight loss over one month.
   
4. Patients with 50% or less consumption of their meals.
   
5. Patients with low albumin or pre-albumin.
   
6. Patients with vitamin deficiency.

References

1. Enteral nutritional support in prevention and treatment of pressure ulcers: A systematic review and meta-analysis. Rebecca J. Stratton, et,al. Aging research Reviews 2005.
2. Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial. Hartgrink HH, et,al. Clinical Nutrition 1998.
3. The National Pressure Ulcer Long-Term Care Study: Pressure Ulcer Development in Long-Term Care Residents. Horn Susan, et,al. Journal of the American Geriatrics Society 2004.
4. Old age, Malnutrition, and Pressure Sores: an Ill-fated Alliance. Mathus-Vliegen Elisabeth. Journal of Gerontology 2004.
5. Nutrients and Wound Healing: Still Searching for the Magic Bullet. Thompson Cheryl, et,al. Nutrition in Clinical Practice 2005.
6. Issues and Dilemmas in the Prevention and Treatment of Pressure Ulcers: A Review. Thomas David. Journal of Gerontology 2001.