Pressure Ulcer Management: Tips from the Field Nutritional Gems

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Pressure Ulcer Management Tips from the
FieldNutritional Gems

• Evelyn Phillips, MS, RD, LDN
• Clinical Nutrition Manager and Researcher
• JHS / Magee Rehabilitation Hospital
• Philadelphia., PA
• ephillips_at_mageerehab.org

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Making the ConnectionInflammationMalnutritionWo
unds
Inflammatory Triggers Acute /or Chronic
Acute Inflammatory Response / Hypermetabolic
State For 2-25 days post injury
AKA Cachexia
1. Assessment of a prognostic biochemical
indicator of nutrition and inflammation for
pressure ulcer risk. Reynolds et al. J Clin
Pathol.2006 59 308-310
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Inflammatory Conditions withNutritional
ImplicationsSame as Risks for Pressure Ulcers

• Aging
• Burns, Trauma, Surgery
• Hyperglycemia
• Immobility
• Infections, Fever, Sepsis
• Long-bone fractures
• Periodontal Disease
• Pressure Ulcers

• Chronic/Acute illness DM, CVD, RA, DJD, IBD, MS,
  ALS, GBS, Obesity, Metabolic Syndrome,
  Hyperthyroidism, CKD, ESRD, SCI
• Prolonged steroids

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Common risk factors for malnutrition as well as
pressure ulcer formation or progression.Same as
group for inflammatory conditions.

• Recent Metabolic Stress
• H/O pressure ulcers
• Advanced Age
• Poor nutritional status
• Underweight, Recent IWL, Obesity
• ? ALB PAB
• Poor Glycemic Control
• Compromised Intake
• Dehydration

• Malabsorption
• Bowel Ds / Diarrhea
• Alblt 3.0 Anasarca
• Ostomies / Fistulas
• Comorbidities
• DM, CKD, CVD, COPD
• Functional dependence
• Immobility
• Poor circulation, PVD
• Incontinence
• Poor skin condition

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Making the ConnectionCachexia (Inflammatory
Malnutrition)

• Develops when there is underlying inflammatory
  process, injury, or condition
• ? Cytokines ? Catabolic state Anorexia
• Amino acids exported from muscle to liver
• Erosion of body cell mass
• ?Positive w/?Negative acute phase proteins
• ?Alb ? Extracellular fluid ? obvious edema
• Nutrition alone is not effective

Jensen JL. Inflammation as the key interface of
the medical and nutrition universes A
provocative examination of the future of clinical
nutrition and medicine. JPEN. 200630(5)453-463.
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InflammationMalnutritionWoundsBiologic
Markers of Inflammation ? CRP with ? ALB ? PAB

• ? CRP in ICU
• ? Organ failure, poor outcomes and death1
• ?PAB
• Inflammatory Marker2
• lt 13.7 /- 3.8 mg/dl
• ? Risk for pressure ulcer
• ? Blood glucose3

• ALB (normal hydration)
• lt 2.5 ? Diarrhea4
• lt 3.0 Stagnant wound with VAC5
• lt 3.5 Poor outcomes ? Risk for pressure
  ulcer6

1. CHEST 2003 12320432049. 2. Devakonda, et
al. Transthyretin as a marker to predict outcome
in critically ill patients. Clin Biochem. 2008
Jul 3 (ahead of print). 3. Van den Berghe et al.
Intensive insulin therapy in critically ill
patients. NEJM. 20013451359-1367. 4.
Crit-Care-Med. 1988 Feb 16(2) 130-6 5. Bowman
and Spungen, 2008. 6. NPUAP.ORG
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Barriers We See at Magee Poor or Inappropriate
Oral Intake

• Illness/Meds / Pain / Depressed / Dysphagia
• High calorie / sugar supplements
• Juice Abuse / Excessive intake
• Megace Excessive Appetite and
• Lowers testosterone
• Increases water fat weight
• Hyperglycemia
• Increased risk for thrombosis

Already present In SCI
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Barriers We See at Magee Inappropriate Tube
Feedings

• Malnutrition malabsorption treated w/
• Fiber TF/Dehydration Impactions
• Standard TF Intact protein, ?N6/?MCT
• Tolerating TF w/diarrhea Rectal tubes
• Delay or no tube placed
• Aspiration Risk Bolus TF/Diarrhea
• Excessive Calories

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35 year old Paraplegic with necrosis of the
Prostate gland and multiple recurrent ischial,
perineal, and sacral wounds.
InflammationMalnutritionWounds
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Pressure Ulcer as Marker of Inflammation
Malnutrition?
This patient required aggressive nutrition
support to save his life prior to developing a
strategy to reconstruct his perineum.
Removal of dead tissue helps reduce inflammation
/ oxidative stress.
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Inflammatory Response

• Increase
• Catecholamine
• Cortisol
• Decrease
• Insulin
• Testosterone
• Altered growth hormone

• Loss of LBM
• Impaired physiologic
• \functions (Hill, 1992)
• ? Self pressure relief ability
• Loss of GI Integrity
• Loss of appetite
• Malabsorption Diarrhea
• Poor Wound Healing
• Spontaneous Pressure Ulcers
• Mortality _at_ 40 Loss of LBM

• Insulin resistance
• Oxidative stress
• Altered nutrient
• utilization

Demling, 2001
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Pressure UlcerMarker of Inflammation
Malnutrition
Increased Insulin Resistance
LBM for energy Arg, Gln, Cys, Gly conditionally
essential. ? anti-oxidants use
Energy Stores Energy from Glucose Amino Acids.
Fat Stores 70 Recycled 30 for Energy


Drainage Fluid, protein zinc losses.
Wound Inflammatory Trigger

• Loss of Gut Integrity
• Malabsorption Diarrhea
• ? Nutrient Losses
• ? Oxidative stress

Graphics Demling, 2001
30 g Pro/day1
1. Thomas B. Catabolic states. In Thomas B, ed.
British Dietetic Association Manual of Dietetic
Practice. Oxford, UK Blackwell
Scientific1994537549.
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Intervene Early (lt36hrs) Control Inflammation
Preserve Gut Integrity

• Breaking the NPO mindset
• Lack of enteral stimulation results in atrophy of
  Gut Associated Lymph Tissue (GALT)
• The Gut then becomes pro-inflammatory by
  up-regulating IL-2, IL-5, and TNF-b.
• These cytokines travel to the respiratory system
  via the lymphatic system contributing to
  respiratory distress
• (EE Moore Trauma 199437-881)

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InflammationMalnutritionWoundsEarly
Intervention

• Meet at least 65 of needs within 3-4 days
• Include feeding tube placement in
  trauma/surgical/critical care protocols
• Provide enteral stimulus w/ TPN as able
• Leave the tube in until adequate consistent
  oral intake for solids liquids is demonstrated
• Use for partial hs TF, fluids, supplements, meds
• Allow secondary facility to remove, note
  placement date

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InflammationMalnutritionWoundsEarly
Intervention

• Be mindful of time on NPO/Clear Liquids
• Include protein supplement w/clear liquid diet
• Monitor intake. If indicated, need to be
  proactive in PEG placement to help prevent skin
  breakdown.
• Ensure adequate p.o. fluids or feeding tube
  flushes before stopping IVF.

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Nutritional Gems The Pearls of Intervention
Let them eat Cake!
Limed evidence to support specific nutrient
levels for wound healing. All wounds will
heal What happens when they dont?
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Treating Inflammation as Part of Nutrition
Management of Pressure Ulcers

Disease Specific Interventions
Usual Nutrient Needs

• Modulate Inflammation Reduce Oxidative Stress
• Restore Gut Integrity
• Glycemic control
• Prevent/Correct Diarrhea
• Facilitate protein absorption
• Support tissue repair / scar formation / replace
  nutrients lost in wound drainage
• Assess tolerance/progress frequently, adjust prn

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The Pearls of Intervention Determine Your
Starting Point

• Co morbidities Tally inflammatory conditions
  present
• Meds that ? insulin resistance, steroids,
  megestrol acetate
• Significant Weight Loss, Under or Over weight?
• ? 1-2 in 1 week 5 in 30 days 7.5 in 3
  months 10 in 6 months
• BMI lt 18.5 or gt30 (gt27 in ICU)
• Poor intake gt 7 days, constipation BOWEL
  ROUTINE
• Physical S/S of malnutrition, dehydration and
  deficiencies
• Diarrhea gt 3 days
• Labs ?BS, ?CRP, ?PAB. ALB lt 3.5, 3.0, 2.5 mg/dL?

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The Pearls of InterventionWound Status as
Inflammatory Marker

• Non-Healing
• Unstageable, DTI or Stage 3 4
• Heavy exudate
• Pale wound bed
• In Clinical Practice
• Correlates with ? CRP
• anorexia, ? taste acuity, diarrhea

Albumin 1.8 g/dl
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Loss of Gut Integrity Outside View
Diarrhea Reduces Tissue Tolerance to Pressure

• Moisture, Fungal Infection, Excoriation
• Sheering from frequent clean ups
• Dehydration from fluid losses
• Malnutrition from increased nutrient losses
• Can contaminate existing wounds

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The Pearls of InterventionPrioritizing Nutrition
Interventions

• Putting protein and calories in their place
• Hydration
• Glycemic control
• Protein
• Calories

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The Pearls of Intervention Fluids First!

• Do Not increase protein w/o adequate fluids 1st
• Fluids as Med Pass, even without meds
• Educate patient/family/visitors to push fluids
• OT to maximize independence with drinking
• Self flushing TF pumps more than 25 mLs/hr
• PEG tube for fluids only?
• Monitor for when IVFs are discontinued, adjust
  other fluids prn.

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The Pearls of InterventionFluids Enteral Tube
Feedings

• How much fluid comes from solid foods?
• Typical enteral formula water content
• 1.0 cal/mL 80 1.5 cal/mL 75
• 6 150 lb male draining Stage IV pressure
  ulcer
• 1.5 to 2.0g Pro/kg 100 -135g
• 35 ml or kcal/kg 2400 mLs kcals
• 1.0/1.5 1900/1200 mLs from TF
• 1.0/1.5 500/1200 mLs needed from flushes

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The Pearls of Intervention Fluids First!

• Additional protein is not always appropriate
• If unable to correct dehydration, can not
  increase protein -- wound healing may not be the
  goal.
• Monitor hydration status with additional protein
• Serum values, urine osmolality, oral cavity
• Check output N/V/D, wound drainage, fistulas,
  ostomies, sweating, hyperglycemia, Diabetes
  Insipidus, medications.

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Case Study

• 57y.o. Female. CHF s/p VDRF, trach, pacemaker,
  PEG, CRI, Stage IV coccygeal ulcer to rehab for
  deconditioning
• PMH Nonischemic cardiomyopathy, DM2, CKD.
• Nutrition orders per transfer chart
• Cardiac diet w/2000 mls fluid restriction
• Renal TF _at_ 50mls/hr X 12hrs 42g Pro / 1200
  cals
• 3 scoops of protein powder TID 45g Pro /
  270 cals
• Canned 1.5 supplement TID 39g Pro /
  1080 cals
• Arg/Gln /HMB supplement TID 65 N2 eqv /
  235 cals/ 810mg K / 285mg Phos
• 3g Pro/kg 64 kcals/kg

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The Pearls of InterventionGlycemic Control

• In practice, not all patients benefit from high
  calorie interventions
• May need to underfeed at first, adjust meds, then
  increase calories as able / as appropriate
• Hyperglycemia Overfeeding Pro-Inflammatory
• Continued loss of LBM
• Dehydration
• Impaired immune function, Infection risk
• Poor wound healing

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The Pearls of Intervention Glycemic Control Tips

• Consider sugar free or low carbohydrate products
  even for non-diabetics
• Consider products w/ higher of fat as MCT
• MCT readily absorbed, maintain caloric density
  with less CHO and less pro- inflammatory omega 6
  fat
• Dysphagia
• Offer variety of thickened liquids, limit juice
• i.e., water, milk, sugar free/decaf beverages

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Case Study JR

• 34 yo Portuguese male PMH Ø
• C4 Asia A Quadriplegia s/p fall 2/15
• S/P multiple C-spine surgeries
• S/P Trach and PEG 2/15
• Complications
• Hypotension DVT PE VDRF Esophagealcutaneous
  fistula s/p multiple repairs, Repeated aspiration
  pneumonia Line infections and 4 pressure ulcers
  Stages 2-3.

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Case Study JR

• 4 Pressure Ulcers
• Two Stage 2 Sacral, min drainage
• Stage 3 Sacral, moderate drainage
• Stage 3 intergluteal with significant drainage.

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Case Study JR

• Review of Transfer Nutrition RX
• NPO with early start of standard high protein TF
  _at_ 55mls ATC 35kcals/kg and 1.8gpro/kg.
• TF advanced once wound care was addressed to
  70mls/hr providing 50 kcal/kg 2.8 g/pro kg
• PT noted to have episodes of N/V/D
• PAB trending downward despite or due to (?)
  advancement in TF rate

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Case Study JR

• Weight Assessment
• UBW 158 Admit Wt 110
• IBW SCI 139-144 /-10
• Loss 30 79 of IBW for SCI
• Intervention
• TF 27 kcal/kg and 2.0 g/ kg protein 15 g Arg
  20g Gln 1g Vit C 35mg Zn
• Oxandrolone 10 mg bid
• Flushes 250 ml q 4 hrs (Total fluid 45mls/kg)

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Case JR Weight Laboratory Trends
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The Pearls of InterventionFats and Inflammation

• Medium Chain Triglycerides MCT
• Neutral Omega 6 Fat (palm or coconut oil)
• More readily absorbed better bowel tolerance
• Fatty acids
• Omega 3 Anti-inflammatory properties
• Omega 6 Primarily pro-inflammatory
• Ideal Ratio O 6 O 3 31. US diet 201
• Most Products Low O 3 only 20 fat as MCT

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59 y.o. male s/p MVA Tetraplegia, trach, PEG,
colostomy, hyperglycemia and stage IV sacral
pressure ulcer. PMH HTN

• Acute care regimen
• NPO on 24hr TF
• 2200 kcals 125g Pro
• Standard 1.5 cal/ml high fiber formula, lt20 of
  fat as MCT
• 3 scoops of protein powder bid

• Our Regimen
• NPO, on 14hr TF
• 2200 kcals 125g Pro plus arg gln
• Elemental 1.5 cal/ml formula with protein as
  small peptides 70 of fat as MCT
• 30mls liquid pro bid
• Arg/gln combo bid and 1 pack powdered MV

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59 y.o. male s/p MVA Tetraplegia, trach, PEG,
colostomy, hyperglycemia and stage IV sacral
pressure ulcer. PMH HTN

• Acute care regimen
• 40 units 70/30 bid
• SS start at BG of 130 80-86 units/day.
• Average BG for past 48 hours 150, range of 60 to
  225
• Watery stools per colostomy

• Our Regimen
• 20 units NPH with start of TF at 6pm, 28 units of
  NPH by day 4.
• SS start at BG of 150.
• Average 3 day BG 135, range of 97 to 165 Average
  BG day 4-7 117, range of 90 to 130
• Pasty stools per colostomy

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The Pearls of Intervention Protein

• Adequate stores modulate inflammation
• Immune function, enzymes, cytokines, hormones
• 1.2-1.5g/kg/d, up to 2g/kg/d for large draining
  wounds
• High risk for dehydration with 2.5g/kg/d
• Need to reassess needs with weight changes
• Use IBW or estimated dry Wt if edema present
• Use upper range of IBW for obesity

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The Pearls of Intervention Protein Facilitate
Absorption

• If Albumin is lt 3.0 (diarrhea likely)
• Enteral Feeding
• Consider elemental TF with protein as small
  peptides
• A high fiber TF will not correct malabsorption
  diarrhea
• Consider pre/probiotics, soluble fiber, banana
  flakes
• Oral Supplements
• Consider hydrolyzed liquid protein supplement
• Standard supplements may cause dumping with ALB lt
  2.5
• Consider pre/probiotics, soluble fiber, banana
  flakes or chips

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Why Peptide Based Enteral Formula? To Facilitate
Protein Absorption

• Inflammation suppresses protein synthesis
• Small peptides, lt 50 amino acids, are absorbed
  directly they do not rely on digestive enzymes
  (proteins) as do intact proteins larger
  peptides.
• Improve N2 balance visceral protein synthesis
• Improved visceral proteins help to modulate
  inflammation

Borlase BC, et al. Surgery, Gyn Obstetrics.
1992174181-188. Cummings JH, et al. Am J Clin
Nutr. 200173415S 420S. Roberts PR, et al.
Nutrition. 199814266-269. Rowe B, et al. J Am
Coll Nutr. 1994124323-330.
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The Pearls of InterventionMicronutrients No
Magic Bullet

• ALL are important, even the undiscovered ones
• Synergistic Competitive
• Can not be studied individually often act
  indirectly
• Modulators of inflammation
• Utilization increases during metabolic stress
• Lost in wound drainage, i.e. Zn is in 200 MMPs
• Absorption/requirements influenced by
• Age, sex, medications, activity, illness, diet,
  smoking, environmental and genetic factors

A C Zn E Mg B6 Cu D
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The Pearls of InterventionMicronutrients No
Magic Bullet

• Supplement if deficiency is suspected or
  present
• How is this to be determined?
• What about sub-clinical or prevention of
  deficiencies?
• Reasonable to give RDI
• Clinical Practice Higher levels with heavily
  draining wounds for 2-4 weeks or less based on
  drainage/healing.

A C Zn E Mg B6 Cu D
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The Pearls of InterventionMicronutrients No
Magic Bullet

• Check your vitamin
• Standard MV contains only 6 micronutrients
• Liquid MV can still be inadequate
• Therapeutic MV may not breakdown, especially with
  ostomies, diarrhea, or impaired GI integrity
• Clinical Practice
• Chewable or powder/dissolvable Therapeutic MV

A C Zn E Mg B6 Cu D
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Vitamin C Benefits may be direct or indirect

• Acts to decrease free radical damage at site of
  wound and reduces whole body stress
• Decreases edema increase vascular density
• Improved pulmonary function increased profusion
• The tolerable upper intake level in adults is
  2000 mg/d.

Nutrition and Wound Healing. Molnar JA. Taylor
Francis Group LLC, Boca Raton, FL. 2007. Protein
powders, portions and elixirs. Litchford, MD.
Case Sotware Books, Greensboro, NC. 2007.
http//www.nlm.nih.gov/medlineplus/druginfo/natura
l/patient-vitaminc.html
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The Role of Conditionally Essential Nutrients

• A nutrient that is usually produced in adequate
  amounts by endogenous synthesis but that is
  exogenously required under certain circumstances.
  Arginine, glutamine, cysteine, glycine,
  carnitine, and choline, are classified as
  conditionally essential nutrients.

Fontana Gallego L, Sáez Lara MJ, Santisteban
Bailón R, Gil Hernández A. Nitrogenous compounds
of interest in clinical nutrition. Nutr Hosp.
2006 May 21 Suppl 214-27, 15-29. Review.
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The Pearls of InterventionArginine

• Conditionally essential in GI disease, TPN,
  growth, pregnancy, severe stress, trauma, protein
  deficiency malnutrition
• Depletion impairs wound healing results in
  decreased wound breaking strength.
• Adequate supplies rely on glutamine proline
  availability to maintain positive nitrogen balance

Zieve l. Conditional deficiencies of ornithine
and argine. J. Am. Coll. Nutr. 5,167-176,1986. Och
oa et al. Nutr Clin Prac. 20046(19)216-225.
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Arginine as Modulator of InflammationSole
Substrate for Nitric Oxide

• Increases wound gut profusion.
• Improved healing of burn wounds, reducing the
  infection rate hospital LOS with supplemental
  arginine.
• Impaired diabetic wound healing can be corrected
  with supplemented Arg which enhances wound NO
  synthesis.
• Supplemental Arg (6g/day), is safe effective
  in potentiating surgical angiogenesis in humans.
  Ruel, 2008
• Caution with septic patients

Barbul., et al. Arginine enhance wound healing
and lymphocyte immune response in humans. Surg
108, 331-337, 1990. Kiyama A., et al. Trauma and
wound healing role of the route of nutritional
support. J. Surg. Invest., 2, 483-489, 2001.
Witte et al., Metabolism,51, 1269-1272, 2002
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The Pearls of InterventionGlutamine as a
Modulator of Inflammation

• In catabolic patients lack of Gln causes loss of
  gut integrity decreases effectiveness of GALT.
• GLN regulates glutathione levels
• Powerful antioxidant for oxidative stress
• Aides in metabolism, protein synthesis, immune
  response cytokine production
• Adequate selenium also needed

Fraga Fuentes MD, de Juana Velasco P, Pintor
Recuenco R. Metabolic role of glutamine and its
importance in nutritional therapy. Nutr Hosp.
1996 Jul-Aug11(4)215-25.
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The Pearls of InterventionGlutamine
Supplementation

• In critical illness
• Decrease in the incidence of infections, LOS,
  reduced N2 loss mortality rate.
• In surgical patients
• Improved immunological parameters,
• Trophic effect on the intestinal mucosa,
• Decreased the intestinal permeability.
• Immunodeficiency in critically ill surgical
  patients may in part be due to decreased gln
  levels.

Fraga Fuentes MD, de Juana Velasco P, Pintor
Recuenco R. Metabolic role of glutamine and its
importance in nutritional therapy. Nutr Hosp.
1996 Jul Aug11(4)215-25.
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The Pearls of InterventionArginine Glutamine
Supplementation

• Arginine caution with renal disease
• High nitrogen amino acid, increased fluid
  requirements
• Metabolism can elevate serum potassium
• Glutamine caution in liver disease
• Metabolism increases ammonia production
• Adequate arginine supplies requires adequate
  glutamine, and both arginine and glutamine
  require adequate protein and micronutrients.

Fraga Fuentes MD, de Juana Velasco P, Pintor
Recuenco R. Metabolic role of glutamine and its
importance in nutritional therapy. Nutr Hosp.
1996 Jul Aug11(4)215-25.
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HMB ß-hydroxy-ß-methylbutyrate

• Metabolite of the indispensible amino acid
  Leucine.
• Rx amount at least 38mg HMB/kg/d, Safe up to
  6g/d
• Current healthcare product w/HMB, previously a
  gym product, purchased by medical nutrition
  company and marketed for wound healing.
• 20 studies to support its ability to increase
  LBM, alone or in combo with arg, gln, lysine, or
  BCAA.
• 7 studies that do not show benefit. Difference in
  outcomes attributed to variation in the level of
  resistant exercise

1. Gallagher, P.M., et al. HMB ingestion, Part
I effects on strength and fat free mass, Med.
Sci. in Sports Exer. 2000322109-2115. 2.
HMB.org
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HMB and Wound Healing

• One study using 35 healthy, human volunteers 70
  years or older showed increased collagen
  deposition with mixture of arg/gln/HMB vs
  placebo.
• Subcutaneous implantation of two small, sterile
  polytetrafluoroethylene tubes into the deltoid
  region under strict aseptic techniques.

• Effect of a specialized amino acid mixture on
  human collagen deposition.
• Williams JZ, Abumrad N, Barbul A. Ann Surg. 2002
  Sep236(3)369-74.

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74 y.o. Central Cord Syndrome s/p FallPMH DM2

• Acute Care
• NPO on Standard high fiber formula
• TF stopped once cleared for p.o. diet
• Questionable Stage 3 sacral ulcer
• Acute Rehab
• Minimal p.o. intake
• Definite Stage 4 sacral wound started on VAC
• TF 1L q HS 1500cal/68gPro
• Oral Arg/Gln/Vit cocktail BID. Supplemental
  protein added when TF discontinued
• Goals BS WNL, Correction of edema, Wound Healing

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Response to Intervention
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Modulating Inflammation Associated with
Non-Healing Pressure Ulcers Not Nutrition for
Wound Healing
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Clinical Practice for Non-Healing Wounds

• Cocktail of arginine, glutamine, protein
  supplement and powdered therapeutic
  multivitamin mineral.
• One-two servings a day based on weight
• Individual components can be added to TF regimen,
  then discontinued as appropriate.
• Arginine and glutamine are never given without a
  supplemental protein source.
• Not used with poor fluid intake, renal, or liver
  disease

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Non-Healing Stage 2, 3 4 /Unstageable Wounds
/DTI Inflammatory Trigger

• Alb lt 3.5 mg/dL ?PAB ? CRP (if available)

• Heavy exudate or VAC
• IWL, likely masked by
• edema

• GI Issues Anorexia,
• Altered taste, Diarrhea
• Hyperglycemia

• Protein/kg 1.5 to 2.0 g
• Kcals/kg 25 to 35, as able
• Arg 15g, max of 20-25g
• Gln 15-20g, max of 30g
• TF Peptide-Based Formula
• Step down to standard intervention in 2-4 wks, as
  able.

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Guidelines for Estimating Needs for Wound Healing
in SCI

• Uncomplicated Stage 1-2
• Fluids 35ml/kg minimum unless contraindicated
• Typically Rx for SCI 2500-3000ml/d
• Micronutrients Therapeutic MVI not a standard
  MVI
• Fatty Acids Goal is to reduce Omega 6s
  increase Omega 3s
• 1.5 to 5 g Fish Oil

Draining or large wounds as above plus Fluids
Adjust amount based on drainage s/s of
dehydration Micronutrients Zinc 40 mg/d
elemental zinc for 4 6 wks, or less if
wound closes. NOT 220 mg ZnSO4 T.I.D. 150
mg of ZN Vit C 500 to 1000 mg/d Vit C
Consider specialized MVI for addl nutrients
( Carnitine, extra Vit C / B / Zn) and to
reduce polypharmacy.
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Good tolerance What to look for

• Close to normal stooling
• Rapid repletion of PAB
• Decreasing CRP
• Glycemic control
• Restoration of appetite/physical function as able
• Weight trending towards goal
• Correction of edema
• Wound healing/prevention
• Intervene early or expect slower recovery

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Synergy
Glutamine Arginine
Vitamin Minerals
Conditionally Essential Amino Acids needed for
metabolic stress
Prevent Deficiency Antioxidants to Reduce
Oxidative Stress
A, C, E, B Complex Zn Cu , Omega 3s
L-Carnatine?
Adequate Fluids
Additional Protein
Consider peptides to Enhance absorption
Adjust per assessment
Adequate, not excessive calories
Use products high in MCT to limit CHOs N6 FAs
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Questions and maybe some answers
Evelyn Phillips, MS, RD, LDN ephillips_at_mageerehab
.org
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(No Transcript)
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Signatures/Date