General Intensive Care Department

1
????? ????? ?? ???? ???
General Intensive Care Department Rabin Medical
Center Petah Tikva
????? ???? ??? 2008
2
??? ???

• ?? ???? ?????? ??? ??? ????? ???? ??? ??????
  ??????? (AHCPR, 1994).
• (????, ???,???? ????? ?? ???? ??? ????
  ???? ?????)

30
36
3
????????? ?? ???? ???

• ??? ?????? ?? ??? ?? ???? ???? ?????? ?? ??? ??
  ?????? ???? ??????????? ?????? ????? ?????? ???
  ?? ???? ?? ???? (?? ??? ????? ????? gt30??"?????
  ).

4
???????? ??" ??????? ?? ??? ???? ??? ???? ????
???? ???? ??? ???" (Reswick Rogers,1976)
5
?????? ????????

• The average- hospital prevalence of
  pressure ulcers is 3 to 12
• hospital subpopulations at high risk
• Critical care units (33 )
  
• Hospitalized quadriplegics( 60)
• Elderly after hip fracture( 60)
• Among patients hospitalised for more than 5 days
  overall one may expect 6 per week to develop
  pressure ulcers.
• The prevalence and incidence of pressure
  ulcers in hospitalised patients in The
  Netherlands A prospective inception cohort
  study Lisette Schoonhoven et all International
  Journal of Nursing Studies 44 (2007)

6
????? ???? ??? ?-EPUA
A randomised, double-blind assessment of the
effect of nutritional supplementation on the
prevention of pressure ulcers in hip-fracture
patients R.H.HOUWING,et all Clinical Nutrition
(2003)
7
????? ??? ????? ?????? ????? ???????
????? ??? ????? ????? ????? ?????? ?????
????????
8
?????????? ???????? ???????? ????????? ????????
?? ????? ???
9
????? ?????
10
Norton Scale
11
Braden Scale
12
Nutritional Management of Pressure Ulcer

• Prevention
• Treatment

13

• Can nutritional care heal pressure ulcers?

It's uncertain what nutritional element would
prevent or heal pressure ulcers.
14
Practical aspects of nutritional support for
wound-healing patients
????? ????? ?????? ??? ?? ??? ???????????? ????
????? ?????? ??? ?? ???? ???? ????? ?????? ??????
????
Jeffrey I. Mechanick American Journal of Surgery
188 (Suppl to July 2004)
15
?? ????? ????? ???
16
??????? ??????? ?????? ??? ??? ?????? ????????
Prevention and Treatment of Pressure UlcersDavid
R. Thomas, MD, J Am Med Dir Assoc 2006
17
????? ?? ???? ??????? ??? ???? ??? ??? ???
???-??? ????
Improving Outcome of Pressure Ulcers with
Nutritional Interventions A Review of the
Evidence David R. Thomas, MD, Nutrition 2001
18
A Multi-Center Trial of the Effects of
OralNutritional Supplementation in Critically
IllOlder Inpatients
9 wards

• ??????? ?????? ???? ??.????
• ????? ???? ???? ????? ????? 2)????? ????? 200
  ?"??
• ???? 672 1This intervention was associated with a
  decreased risk of pressure ulcer

Isabelle Bourdel-Marchasson, MD, et all,
Nutrition 20001615
19
A Multi-Center Trial of the Effects of
OralNutritional Supplementation in Critically
IllOlder Inpatients
???????? ???? ????? ??? ??????? ???????? ??? ???
Isabelle Bourdel-Marchasson, MD, et all,
Nutrition 20001615
20
??????
??' ??????? ?????? ????? ????????? ????? ?????
15 ????? ???? ???????????? ??? 2 ???????
At 15 d, the cumulative incidence of pressure
ulcers was 40.6 in the nutritional intervention
group versus 47.2 in the control group.
21
????? ??????? ?? ????( (250500 kcal
226weeks????? ????? ??????? ??????? ???? ???
??? ??????? ??????
Enteral nutritional support in prevention and
treatment of pressure ulcers A systematic review
and meta-analysis
. odds ratio 0.75, 95 CI 0.620.89, 4 RCTs, n
1224, elderly, post-surgical, chronically

• Rebecca J. et all Ageing Research Reviews 4
  (2005)

22
????? ???????

• ?????? ??????? ??????? ??????
• ??????? ????????
• ?????? ??? ????? ?????.
• ???????
• ????????????????
• ???? ????? ?????? ?????
  ?????? ? ???? ??????
• ????? ?????? ??? -????????
  ?????? NO ???? ?? ????? ??? ??????? ??????
• ???????
• ????? ????? ?????? ????? -
• ???? ??????? ?? ????? ???????? ????? ??????
  ?????? ??????

23
(No Transcript)
24
??????? ????? ?????? ?????? ??? ???? ??? ??????
??????? ????? ????? ????? ???????????
Enteral nutritional support in prevention and
treatment of pressure ulcers A systematic review
and meta-analysis Rebecca J. et all Ageing
Research Reviews 4 (2005)
25
????? ?? ??????? ?????? ??????? ????? ???
??????????????? ??? ???? ???????????
Dietary recommendation for daily protein intake
is 0.8 g z probably too low. for dietary intake
of protein in stressed elderly patients are
between 1.2 and 1.5 g kg
Improving Outcome of Pressure Ulcers with
Nutritional Interventions A Review of the
EvidenceDavid R. Thomas, MD, Nutrition 2001
26
      ?????? - A ??????? ?????? ????? ?????
????? ????? ????? ?????
??????? ??????? ????
???? ???? -????? ???? ????????? ?????? ????
???? ????? ???? ??? ????
???? ??????         ?????? E -
???????????? ??????? ????-??????         ??????
C- ????? ????????????? ?? ?????? ??????
?????? ?????? ?????????
????? -?????? ???????
??????? ???? ?????
???????? ????????
27
???

• ??-????? ???????? ???? ????? ???????? ??????
  ?????? ?????,
• ??????? ?????? ???? ?????
• ????? ?????? ??? ?????? ?????? ?????? ???
• ????? ???? ?????? ?? ???
• ????? ?????? ???????
• .

28
RANDOMIZED CLINICAL TRIAL OF ASCORBIC ACID IN THE
TREATMENT OF PRESSURE ULCERS
500 mg twice daily 10 mg of ascorbic acid twice
daily
????? ?????? ??? ??????? ???????????? ???????
?????? ??? ???? ?????? ??????
GERBEN TER RIET et all Clin Epidemiol. 48 1995
29
?????? ?? ????? ??? ??????? ?? ?????? ??????
???? ????
30
?????? ???? ?-2 ???????
These data do not support the idea that ascorbic
acid supplementation (500 vs. 10 mg twice daily)
speeds up the healing of pressure ulcers
31
A randomised, double-blind assessment of the
effect ofnutritional supplementation on the
prevention of pressureulcers in hip-fracture
patients
????? ?? 400 ?? /??? ?? ????? ??????? ????
???????? ???????????????
(n51) or a non-caloric,water-based placebo
supplement (n52).
R.H.HOUWING,et all Clinical Nutrition (2003)
32
??????? ????????? ?? ???????
33
??????
may not prevent PU at this stage, but contributes
possibly to a delayed onset and progression of PU
34
Effect of early postoperative enteral
immunonutrition on wound healing in patients
undergoing surgery for gastric cancer
Farrerasa,N et all, Clinical Nutrition (2005) 24,
5565

• ????? ????
• ??' ????? ???? ??????????????? (????????????? ??
  ?????? ??????)
• ?????? ?? ??????? ??????? ?????? ????

early postoperative enteral immunonutrition
formula supplemented with arginine,omega-3 fatty
acids and ribonucleic acid (RNA)) or an
isocaloric-isonitrogenous
35
??????? ????????? ???????
36
????? ???????? ???????? ??????? ?????? ???
0 vs. 8 (26.7) P0.005)
37
??????? ?????? ?????? ?????? ???? ???? ??????
???? ?? ??????????????
(59.7 nmol (5.0201.8), vs. 28.0 nmol
38
???? ?????????????? ??? ????? ?? ?? ??? ?????? ??
???
39
Oral glutamine and the healing of colonic
anastomoses in ratsCosta CA et all JPEN, 2003
??? ??? ??????? ?????? ???????? ???? 7 ???? ????
????? ????? ???? ???? ????? ????? ???? ??????
?????? ???? ?3-8
40

• USE OF ARGININE AND GLUTAMINE SUPPLEMENTS TO
• ENHANCE WOUND HEALING IN A LONG-TERM CARE
• M. Litchford, et all 2005
• Arginine and glutamine are used as adjunct
  therapies for wound healing.
• ulcer healed in 37 fewer days than the first
  ulcer with the arginine and glutamine
• supplements.

????? ???????? ???????? ?????? ??? ?????? ??????
???? ????? ?37 ???? ???? ?????? ???????
41
Treatment with supplementary arginine, vitamin
Cand zinc in patients with pressure ulcersA
randomised controlled trial

• standard hospital diet
• a standard diet plus two high-protein/energy
  supplements
• a standard diet two high-protein/energy
  containing additional arginine (9 g), vitamin C
  (500 mg) and zinc (30 mg

Katherine J. et all, Clinical Nutrition (2005)
42
?????? ??????? ??????
43
??????
????? ????? PUSH ????? (8.770.5) ?? ???????
?????? ????? ?? ??????? ?????? C ????? ????
????? ??????? ?????? ???? (9.471.2 vs. 2.670.6
baseline and week 3, respectively P001)
44
???? ?? ??????? ???????? ?? ????? ???
Improving Outcome of Pressure Ulcers with
Nutritional Interventions A Review of the
Evidence David R. Thomas, MD, Nutrition 2001
45
??????? ???????
??????? ?????? ??????? ???? ?????? ??????????
????? ?????? ???? ?? ???? ??????????-????
?????? ????-???? ??????. ?????? ???? ????? 6
?????? ?? ????? ?????????????? ?????? ?????
????? 3 ????? ???? ?????? ???. ???? ???? ?????
???? ?????
46

• The Effect of Nutrition Enriched With
• Fish Oil, Borage Oil and Antioxidants on Pressure
  Ulcers, Metabolic Parameters, among Patients with
  Acute Lung Injury (ALI)
• Theilla M, Fisher H, Gibstein L, Grozovski E ,
  Cohen J , Singer P
• Clinical Nutrition (2007)
• General Intensive Care
  Department
• Rabin
  Medical Center
• 
  Petah Tikva
  Tel Aviv University,
• Israel

47
Primary objectives

• To examine whether the formula enriched with fish
  oil, borage oil and antioxidants contributes to
  decreased inflammation and occurrence of pressure
  ulcers

48
6 ? Comparison of ? 3 with
49
Anti-inflammatory properties of omega-3 fatty
acids in critical illness novel mechanisms and
an integrative perspective Intensive Care Med.
2008 May 7Singer P, Shapiro H, Theilla M, Anbar
R, Singer J, Cohen J.

• ???? ????? ?? FFSA ?????? ?? TLR4/2
• ???? ?????? NFKB ????? ??? ??????
• ??' ??????? ??? ????? ??? ??????????? ?-IKK
• ???????? ??????-??????? ??????? ????? ?????
• ??? PPAR ???????? ?? ???????? ?? ??????
• ???? ?????? ?????? ???? ?????? ????? ???? ??????
  ?????? ?????? ?? TNF,INOS ,COX ,ICAM
• ???? ?????? ?????? ???? ???? ?????

50
METHODS

• One hundred ventilated patients with a PaO2/FiO2
  lt 250
• Prospectively randomized not blinded into two
  groups
• Group one received a formula enriched with ? 6
  fatty acid
• Group two received a formula enriched with ? 3
  and ? 6 fatty acid

51
????? ???????? ?????????
Miryam Theilla, Pierre Singer a, Jonathan
Cohena, Freda DeKeyser Clinical Nutrition (2007)
26, 752757
52
Patients Characteristics 100 patients included,
5 excluded
53
Occurrence of new pressure ulcers in different
groups according to group (in percentage)

?24.77 P0.024
54
??????? ?? ????? ????? ????? ???????
55
Results Vitamins, trace elements and
inflammation markers
56
Vitamin A
SD16.52
SD22.90
SD18.60
SD18.81
SD15.46
SD26.88
SD15.46
SD16.80
SD16.56
57
Vitamin E
SD0.81
SD0.25
SD1.21
SD0.82
SD0.66
SD0.59
SD0.58
SD0.44
58
CU
SD31.50
SD28.56
SD39.99
SD49.76
SD54.21
SD51.19
SD30.71
59
ZN
SD19.99
SD21.50
SD15.98
SD33.88
SD16.06
SD20.93
SD10.16
SD11.47
60
PCT
SD29.19
SD9.97
SD21.55
SD13.44
SD2.99
SD11.78
SD6.44
SD2.76
61
CRP
SD137.13
SD89.84
SD56.71
SD82.44
SD69.31
SD37.18
SD52.34
SD42.98
62
CONCLUSIONS

• Patients with ALI receiving a formula enriched
  with fish oil, borage oil and antioxidants show a
  decrease in the rate of new pressure ulcers
• This improvement was not related to a change in
  vitamins or trace elements.

63
?????

• ?? ????? ????? ???????? ???? ??? ?????
• ??? ????? ??????? ?/?? ????? ????? ???????? ???
  ???
• ??? ????? ???????? ???? ???? ?? ???? ??????
• ??? ????? ?? ??????? ???????,??? ????????? ??????
  ?? ??? ????? ????
• ??? ??????? ????? ?????? 3 ????? ?????? ????????
  ?????- ?????? ?????? ??????

64
Effects of fatty acids and dietary lipids on
cells of the immune system PHILIP C. CALDER
Proceedings of the Nutrition Society (1996
65
(No Transcript)