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Goals Principles in wounds healing Nutrition, the Often Forgotten - - PowerPoint PPT Presentation

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4/16/2016 Goals Principles in wounds healing Nutrition, the Often Forgotten Part of the Equation for Wound Healing Critical Nutrients Role of omega-3 fatty acids Marlene Grenon, MD Associate Professor of Surgery University of

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Nutrition, the Often Forgotten Part

  • f the Equation for Wound Healing

Marlene Grenon, MD Associate Professor of Surgery University of California San Francisco UCSF Vascular Surgery Symposium 2016

Goals

  • Principles in wounds healing
  • Critical Nutrients
  • Role of omega-3 fatty acids

Chronic Wounds

  • Chronic Wounds: Wounds taking >4-6 weeks

to heal

  • Types

– Pressure ulcers – Post-op wounds – Ulcers (venous, arterial) – Burns – Stomas – Amputation wounds

Dorner et al, Adv Skin Wound Care 2009

Nutritional Risk Factors for Impaired Wound Healing

  • Significant weight loss
  • Inadequate protein intake
  • Inadequate nutrient intake
  • Extreme Body Mass index (low or high) with

limited mobility

  • Hypoalbuminemia
  • Dehydration

Dorner et al, Adv Skin Wound Care 2009

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Inflammation (hsCRP> 5mg/L) Malnutrition (albumin < 3.5mg/dl) Renal impairment (eGFR <60 ml/min)

27% 31% 37% 17% 9% 15% 18%

HR=6.7 HR=4.54 HR=2.72 HR=3.77

HR=9.08

HR=5.65 HR=4.10

Owens CD et al J Vasc Surg 2012

Hazard Ratios for Death

Wound Healing

  • wound

exudation

  • fibrin clot
  • neutrophils
  • macrophages
  • epithelialization
  • angiogenesis
  • fibroblast proliferation
  • collagen cross-linking
  • wound contraction
  • collagen maturation
  • tensile strength

Wound Healing

Vitamin A Vitamin C ZInc Protein Protein Glucosamine

American Dietetic Association’s Nutrition Care Process

  • Medical Nutrition

Therapy:

– Nutrition assessment – Nutrition diagnosis – Nutrition intervention – Nutrition monitoring and evaluation

  • Recommended

assessments:

– Anthropometric measurements – Biochemical data (anemias) – Hydration status – Nutrition-focused clinical examination – Diet history

American Dietetic Association 2009

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Critical Nutrients

Water

  • Aid in hydration of wound sites and oxygen perfusion
  • Epithelial cells require moisture to migrate from the

wound edge to close the wound

  • Act as a solvent for minerals, vitamins, amino acids,

glucose

  • Transporting vital materials to cells and removing waste

products

Energy

  • Sources: carbohydrates and fat
  • Wound energy demand: collagen synthesis
  • Requirements 30-35 kcal/kg but need to be individualized

Fats

  • Good source of energy (9cal/g)

and spares protein for wound healing

  • Carries Vitamins A, D, E, K
  • Aids in absorption of Vit A
  • Provides padding under body

prominence and insulation of the skin

  • Overall:

– Underweight: gain weight – Overweight: weight maintenance

  • Sources: meat, full-fat dairy, oils

Williams JZ, Surg Clin N Am 2003; Ord H. Br J Nurs 2007; Edmonds J. Br J Community Nurs 2007

Carbohydrates

  • Stimulate insulin production

+ release

  • Prevent gluconeogenesis
  • Inadequate supplies

– Poor wound healing

  • Caution with diabetes

required

  • Sources: wholegrain cereals,

breads, potatoes, rice, pasta, biscuits

Role of Proteins

  • Maintenance and repair
  • f body tissue

– Collagen synthesis – Fibroblast proliferation – Tissue remodeling – Wound contraction – Maintain oncotic pressure – Skin structure

  • Daily intake of 1-

1.5g/kg/day

  • Up to 3g/kg/day in

severe wounds

  • Protein deficiency

impairs all stages of wound healing

Red and white meats, fish, eggs, liver, dairy products (milk, cheese yogurt), soy beans, legumes, seeds, nuts and grains

Hurd TA, Wound Care 2004; Ord H Br J Nurs 2007

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Amino Acids- L-Arginine

  • Essential structural

protein synthesis and protein metabolism

– Decrease muscle loss

  • Nitric oxide pathway

– Collagen deposition in wound healing

  • Enhance immune

function

  • Improve secretion of

growth hormone and insulin

  • Average dietary intake

provides 4g/day

  • 9 g/day promotes wound

healing for pressure ulcers *

  • Source: proteins
  • Side-effects: diarrhea.

*Desneves KJ, Clin Nutr 2005 Supplementation: Arginine 9g, Vit C (500 mg), zinc (30 mg)

Albumin

  • Albumin and pre-

albumin are a strong prognostic indicator and level of morbidity in many populations

– Albumin half-life almost 21 days – Pre-albumin 3 days

  • Although reflective of

malnutrition, affected by

  • ther conditions
  • hydration status
  • metabolism
  • infection
  • stress
  • liver disease
  • renal disease
  • inflammation

Normal range: 3.4-5.4 g/dL

Vitamin A

  • Increases the

inflammatory response in wounds

  • Stimulates collagen

synthesis and cross- linking

  • Restore wound healing

impaired by long-term steroid therapy or diabetes

– Mechanisms unclear

  • If deficient,

recommended dose: 10,000-25,000 IU x 7-10 days

  • Sources: milk, cheese,

eggs, fish dark green vegetables, oranges, red fruits, vegetables.

Vitamin C

  • Important in collagen

synthesis + crosslinking

  • Angiogenesis
  • Immune system
  • Increases absorption of

iron

  • Deficiency increases the

risk of wound infection

  • If deficient,

recommended dose: 250-1000mg daily

  • Sources: fruit and

vegetables (oranges, grapefruit, tomatoes, leafy vegetables)

  • Side effects: diarrhea,

scurvy

Langemo D. Adv Skin Wound Care 2006; Ord H. Br J Nurs 2007.

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Zinc and Iron

Zinc

  • Protein and collagen

synthesis, tissue growth and healing

  • Recommended intake for

non-healing pressure ulcers, 15-50mg/day (no more than 14 days as it can also interfere with wound healing)

  • Sources: red meat, fish and

shellfish, milk, poultry, eggs.

  • Side-effects: GI complaints

Iron

  • Required in collagen

production and wound strength

  • Recommended intake in the

general population: 8mg/day (18mg/day for menstruating females)

  • Sources: red meat, fish,

eggs, wholemeal bread, dark green leafy vegetables, dried fruits, nuts.

  • Side-effects: nausea and

constipation

Nutrition and Wound healing in PAD

  • double-blinded fashion
  • 270 subjects
  • arginine, glutamine and b-hydroxy-b-methylbutyrate or a control drink
  • 16 weeks
  • >wound closure and time to complete healing

FIGURE 3 Median wound area (cm2) by week; arginine, glutamine and b-hydroxy-b-methylbutyrate supplementation (& ) (n = 129) and Control (s ) (n = 141).

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FIGURE 4 Cumulative probability of wound closure vs. albumin at entry by patient subgroups. Each point (x, y) represents the proportion, y, of subjects with total wound closure in the subgroup of subjects with baseline albumin ≤ x. S pecifically, for the subgroup of subjects (N = 127) with albumin ≤ 40 g/l, proportion healed is higher in the arginine, glutamine and b-hydroxy-b-methylbutyrate supplementation group (& ) (n = 61) vs. thecontrol (s ) (n = 66) (P = 0.0325) Cochran– M antel–Haenszel test stratified by site. FIGURE 5 Cumulativeprobability of wound closure vs. ankle– brachial index at entry by patient. Each point (x, y) represents the proportion, y, of subjects with total wound closure in thesubgroup of subjects with baseline ankle–brachial index ≤ x. S pecifically, for the subgroup of subjects (N = 119) with ankle–brachial index < 1.0, proportion healed is higher in thearginine, glutamine and b-hydroxy- b-methylbutyrate supplementation group (& ) (n = 58) vs. the control group (s ) (n = 61) (P = 0.0079) CM H test stratified by site.

Low albumin subgroup PAD subgroup

Nutrient recommendations CVD

Nosova, JVS 2015

OMEGA Studies + SPMs Studies

OMEGA STUDIES OMEGA- Cross- sectional OMEGA- PAD I OMEGA- PAD II OMEGA- PVI OMEGA EVAR OMEGA- SPM

Total: >200 patients Recruiting (20/70) Completed (n=80) Recruiting (8/30) To start recruitment To start recruitment

Inflammation and Resolution

Serhan CN, Chiang N. Curr Op Pharm 2013

Failure of resolution contributing to chronic inflammation

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Specialized Pro-Resolving Lipid Mediators

COX-1 COX-2 PGE2 TXA2

Prostaglandins Thromboxane

5-LOX LTB4

Leukotrienes

15-LOX LXA4 LXB4

Lipoxins

18-HEPE 5-LOX RvE1 RvE2

E-series Resolvins

15-LOX 17-HpDHA RvD1-RvD4 (N)PD1

D-series Resolvins Protectins

12-LOX or 15-LOX typeI 14-HpDHA MaR1 14-HDHA

Maresins

Arachidonic acid AA Eicosapentaenoic acid EPA Docosahexaenoic acid DHA

17(S)-HDHA

RvD1 RvD2

ω-6 fatty acid ω-3 fatty acid

OMEGA-PAD I Trial: 4.4g fish oil/day in PAD

Grenon et al, JAHA 2015

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Summary

  • Assessment, diagnosis, intervention and

evaluation

– Perform nutritional assessment (weight, pre-albumin level and serum albumin level) – Encourage dietary intake or supplementation – Give vitamin and mineral supplements if deficiencies are confirmed or suspected

  • Dietary consultation
  • Await further trials and evidence

– Promising compounds