EUROPEAN PRESSURE ULCER ADVISORY PANEL

Houniet, H, MSc RD1

1 Nutricia Nederland B.V., The Netherlands.

Nutritional assessment
Nutritional assessment can help the clinician to identify whether a patient is at risk of impaired wound healing. It is impossible to accurately measure nutritional status using only one biochemical or physical measurement. There are, however, a number of anthropometric data, biochemical data, clinical data and data from dietary history which provide a good estimate of nutritional health (Kaminsky, 1989). For example, a 5% weight loss in 30 days or a 10% weight loss in 180 days puts a patient at risk for malnutrition, pressure ulcer development, and impaired wound healing (Flanigan, 1997).

Prevalence of malnutrition
On admission to the hospital, 25% to 45% of all patients are malnourished (Coates 1993; McWhriter 1994; Naber 1997; Postma 1993). In patient groups at risk for developing PU, malnutrition rates are even higher; 64% of elderly patients hospitalized with an acute hip fracture (Sullivan, 1998) and 59% of nursing home patients were malnourished (Pinchofsky, 1986).

Malnutrition delays wound healing
Malnutrition and specific nutrient deficiencies compromise the body’s wound healing process while the overall effects of poor nutritional intake increase an individual’s susceptibility to pressure sore development (Albina, 1994; Breslow, 1994; Ek, 1991; Pinchosfsky, 1986). Therefore an adequate energy and protein intake are essential in order to prevent protein energy malnutrition.

Macronutrients
Providing additional calories alone is insufficient. Protein is the most important macronutrient for wound healing. It aids in revascularisation, fibroblastic proliferation, collagen synthesis, and lymphatic formation. Patients fed high protein diets with adequate calories show improved PU healing (Allman 1986; Breslow, 1993; Chernoff 1990). Specific amino acids may also play an important role. For example, the amino acid arginine has been shown to enhance collagen deposition at the wound site. In addition, arginine enhances cellular immune activities, especially T-cell function, and arginine reduces urinary nitrogen losses and protein catabolism after injury (Barbul 1990, Kirk 1993).

Micronutrients
Vitamin C plays a major role in wound healing because it is essential for collagen synthesis and fibroblast formation (Ehrlichman, 1991). A vitamin C deficiency is associated with increased risk of PU development and prolonged healing (Goode, 1992). A deficiency state can occur rapidly when vitamin C is not present in the diet.

Another vitamin that plays a key role in wound healing is vitamin A. Supplemental vitamin A has been found to affect wound healing by enhancing the early inflammatory reaction, modulating collagenase activity, stimulating epithelial cells and stimulating immune responsiveness (Hunt, 1986).

Zinc is the most well known element in wound healing. It is necessary for cell mitosis and cell proliferation (Solo-man, 1988). In zinc deficiency, fibroblast proliferation and collagen synthesis are decreased. Overall wound strength is impaired, and epithelialisation is delayed. These defects are reversed by zinc supplementation.

Nutritional support
Malnutrition can result in delayed wound healing, and early nutritional intervention may influence the rate of healing (Konstantinides, 1993). If patients are unable to meet their nutritional requirements, oral nutritional supplements should be considered. The cost of supplementation is far less than the costs associated with poor wound healing seen in undernourished patients (Haalboom 1991, Pinchofsky 1986). Dietitians should provide a high-energy, high-protein diet for patients at risk of development of PU to improve their dietary intake and nutritional status (Breslow, 1994).

References

• Albina J.E. (1994). Nutrition and wound healing. JPEN 18: 367-376.
• Allman R.M., Goode P.S., Marha M.D., et al. (1995). Pressure ulcer risk factors among hospitalized patients with activity limitation. J.A.M.A. 273: 865-870.
• Barbul A., Lazarou S.A., Efron D.T., Wasserkrug H.L., Efron G. (1990). Arginine enhances wound healing and lymphocyte immune responses in humans. Surgery 108: 331–337.
• Breslow R.A., Bergstrom N. (1994). Nutritonal prediction of pressure ulcers. JADA 94: 1301–1304.
• Breslow R.A., Hallfrisch J., Guy D.C., Crauwly D., Goldberg A.P. (1993). Importance of dietary protein in healing pressure ulcers. J. Am. Geriatr. Soc. 41: 357–362.
• Breslow R.A., Hallfrisch J., Guy D.G. (1994). Importance of dietary protein in healing pressure ulcers. Nutr. Clin. Pract. 9: 80–81.
• Chernoff R.S., Milton K.Y., Lipschitz D.A. (1990). The effect of a high protein fomula (Replete) on decubitus ulcer healing in long term tube fed institutionalized patients. J. Am. Diet. Assoc. 90: A–130.
• Coates K., Morgan S., Bartolucci A. et al. (1993). Hospital-associated malnutrition: A re-evaluation 12 years later. JADA 93: 27–33.
• Ehrlichman R.J., Seckel B.R., et al. (1991). Common complications of wound healing: prevention and management. Surg. Clin. North Am. 71: 13–23.
• Ek A.-C., Unosson M., Larsson J., Von Schenk H., Bjurulf P. (1991). The development and healing of pressure sores related to the nutritional state. Clin. Nutr. 10: 245–250.
• Flanigan K.H.(1997). Nutritional aspects of wound healing. Adv. Wound Care. 10(2): 48–52.
• Goode H.F. Burns E. Walker B.E. (1992). Vitamin C depletion and pressure sores in ederly patients with and femoral neck fracture. Br. Med. J. 305: 925–927.
• Haalboom J.R.E. (1991). De kosten van decubitus. Ned. T. Geneesk. 135: 606–610.
• Hunt T.K. (1986). Vitamin A and wound healing. J. Am. Acad. Dermatol. 15: 817–821.
• Kaminsky M.V., Pinchcofsky-Cevin G., Williams S.D. (1989). Nutritional management of decubitus ulcers in the elderly. Decubitus 2: 20–30.
• Kirk S.J., Hurson M., Regan M.C., Holt D.R., Wasserkrug H.L., Barbul A. (1993). Arginine stimulates wound healing and immune function in elderly human beings. Surgery 114: 155–160.
• Ehrlichman R.J., Seckel B.R., et al. (1991). Common complications of wound healing: prevention and management. Surg. Clin. North Am. 71: 13–23.
• Konstantinides N., Lehmann S. (1993). The impact of nutrition on wound healing. Critical Care Nurse. 13: 25–33.
• Mcwhirter J.P. (1994). Incidence and recognition of malnutrition in hospital. BMJ 308: 945-948.
• Naber T.H.J. et al. (1997). Prevalence of malnutrition in nonsurgical hospitalized patients and its association with disease cmplications. Am. J. Clin. Nutr. 66: 1232–1239.
• Pinchofsky-Devin G.D., Kaminski M.V. (1986). Correlation of pressure sores with nutritional status. JAGS 34: 345–440.
• Postma B., Wesorp R.I.C. (1993). Depletie of ondervoeding in het ziekenhuis. In: Ondervoeding in het ziekenhuis. Stasse-Wolthuis M., Douwes A.C. (ed.) Houten/Zaventem, Bohn Stafleu Van Loghum. 1–9.
• Soloman N.W. (1998). Zinc and copper. In: Shils M.E., Young V.R. (ed). Modern nutrition in health and disease. Philadelphia: Lea & Febiger. 238–262.
• Sullivan D.H., Nelson C.L., Bopps M.M., et al. (1998). Nightly enteral nutrition support of elderly hip fracture patients: a phase 1 trial. J Am Coll Nutr 17: 155–161.

MEASUREMENT OF SUBCUTANEOUS TISSUE - PRESSURE AND pO2 OVER THE OS SACRUM

Hans Ullrich Völker, Gerhard Röper, Christian Willy and Heinz Gerngroß
Department of Surgery, Military Hospital Ulm, Dept of Surgery,
Oberer Eselberg 40, D–89070, Ulm, Germany

In this study the influence of soft care mattresses on subcutaneous tissue-pressure and pO2 has been examined.

In 14 young volunteers 3 probes were implanted in the subcutaneous tissue over the os sacrum to measure pressure and pO2. Then the probands were asked to lie on a standard mattress, on 8 special beds of various kinds and on 3 dymanic soft care systems for 20-minute periods.

The standard mattress pressure values amounted to 25.5 mmHg (± 5.2; n = 14). The gel cushion showed increased values (26.9 ± 9.5 mmHg; n = 5). Compared to the standard mattress the other systems showed reductions in pressure from 32.7% to 83.1%. The lowest pressure was generated with an air mattress (8.3 ± 2.3 mmHg n=5).

The initial values of pO2 before lying down varied from individual to individual (26.9 – 71.3 mmHg). In the course of the 20-minute periods the values sometimes remained constant, sometimes increased and at other times it decreased. Under extreme conditions (eight probands asked to lie on the floor) a correlation (r = –0.787) between pressure and pO2 was observed (pressure values between 20.6 and 192.9 mmHg). The results show with the subcutaneous pressure reduction through the use of soft care systems and no appreciable decrease of pO2. The use of special beds should be indicated depending on the individual risk of pressure sores.