innovative nutrition management in wound healing

Transcription

INNOVATIVE NUTRITION MANAGEMENT IN WOUND HEALING
Terry TING, Dietitian, MSc, MBA,
President‐elect of HK Nutrition Association, Topics
For your information!
• Older people are at high risk of developing pressure ulcers, as reflected in the fact that 70‐73% of those develop pressure ulcer are over 65 years old. (Whitington et al 2000, Thomas 2006)
• Incidence of the pressure ulcer in hospitalized patient 6.2% and 8.8 %. ( Baumgarten et al .2003,2006)
• 1.61 % for older patient in an outpatient setting. ( Margous et al.2003)
• The pressure sore incidence is 25.16% in Hong Kong Nursing Home.( Wai‐yung Kwong et al 2009)
Function of Some Key Nutrients Involved in Wound Healing
• Proteins (Amino acids)
• Needed for platelet function, neovascularization, lymphocyte formation, fibroblast proliferation, collagen synthesis, and wound remodelling
• Required for certain cell‐mediated responses, including phagocytosis and intracellular killing of bacteria
• Gluconeogenic precursors
• CHO (Glucose)
• Energy substrate of leukocytes and fibroblast
• Fats (fatty acids and cholesterol)
• Serve as building blocks for protaglandins, isoprostanes
• Energy source of some cell types
• Are constituents of triglycerides and fatty acids contained in cellular and subcellular membranes
Impact of Malnutrition on Clinical Outcomes
Protein & Kcal Depletion
Nutrition Care Process
Loss of Lean Body Mass
Poor wound healing
Impaired Impaired Ventilator Ventilator capacity
capacity
Impaired Impaired organ function
organ function
Suppress immune
Increase infection or sepsis
SIRD‐MOD‐MOF
Increase mortality
Prof J Asprer, Nutritional Immunomodulation
in Critical Illness, 2009
營養不良的併發症
•抑壓免疫系統
•影響傷口癒合
•增加住院日數
•增加感染的風險
•影響精神狀態
•增加再入院率
•增加醫療費用
•增加發病率
•增加死亡率
References:
•Lisa A. Barker, et al, 2011
•BAPEN (British Association for Parenteral and Enteral
Nutrition) Quality Group, 2010
•Christian Löser. 2010
Nutrient Requirement for wound healing
Which Nutrient is the most important for wound healing??
=
• Proteins (Amino acids)
• Needed for platelet function, neovascularization, lymphocyte formation, fibroblast proliferation, collagen synthesis, and wound remodelling
• Required for certain cell‐mediated responses, including phagocytosis and intracellular killing of bacteria
• Gluconeogenic precursors
• CHO (Glucose)
• Energy substrate of leukocytes and fibroblast
• Protein sparing effect
• Fats (fatty acids and cholesterol)
• Serve as building blocks for protaglandins, isoprostanes
• Energy source of some cell types
• Are constituents of triglycerides and fatty acids contained in cellular and subcellular membranes
• Protein sparing effect

Vitamin C

B Vitamins

Hydroxylates proline and lysine in collagen synthesis
Free radical scavenger
Necessary component of complement that functions in immune reactions and increases defenses to infection
Serves as cofactor of enzyme systems
Required for antibody formation and white blood cell function, essential for nucleic acid metabolism
Vitamin A

Enhance epithelialization of cell membrane
Enhance rate of collagen synthesis and cross‐linkng of newly formed collagen
Antagonizes the inhibitory effects of glucocorticoids on cell membranes

Vitamin D

Necessary for absorption, transport, and metabolism of calcium

Indirectly affects phosphorus metabolism
Vitamin E

Free radical scavenger
Vitamin K

Needed for synthesis of prothrombin and clotting factors VII, IX, and X

Required for Ca‐binding protein

Zinc

Stablizes cell membranes; enzyme cofactors

Needed for cell mitosis and cell proliferation in wound repair
Iron

Needed for hydroxylation of proline and lysine in collagen synthesis

Enhances bactericidal activity of leukocytes

Haemoglobin oxygen transport to wound
Copper

Integral part of the enzyme lysyloxidase, which catalyzes formation of stable collagen cross‐links
Nutrition Support for wound healing
Energy and Nutrient Requirements of Patients with Sore
• Energy
• Use indirect calorimeter to measure the energy need
• 30 – 40kcal/kg body weight per day • Harris‐Benedict times stress factor (1.2 for stage II ulcer, 1.5 for stage III and IV ulcers) ~ usually over estimated
• Protein
• The recommended range of protein 1.25 to 1.5g/kg BW (AHCPR 1994,
EPUAP 2009)
• 1.5g/kg BW to improved nitrogen balance (ESPEN 2009)
• 2.0 grams per kilogram body weight may not increase protein synthesis and may contribute to dehydration in the elderly
Conventional Options of Nutrition Support
• Modification of Hospital Diet
• Suit therapeutic needs
• Energy‐ and/or protein‐dense foods
• Modify food choices to suit personal preferences/needs
• Oral supplement
• Complete nutrition liquid formulaes
• Regular and disease‐specific
• Modular supplements
• e.g. Energy, protein, fat or fibre supplements
• Tube feeding
• Indicative for patients with dysphagia or persistent poor oral intake
營養不良的併發症
•抑壓免疫系統
•影響傷口癒合
•增加住院日數
•增加感染的風險
•影響精神狀態
•增加再入院率
•增加醫療費用
•增加發病率
•增加死亡率
References:
•Lisa A. Barker, et al, 2011
•BAPEN (British Association for Parenteral and Enteral
Nutrition) Quality Group, 2010
•Christian Löser. 2010
Challenges in Meeting Nutrient Requirements • ? SKY HIGH energy and nutrient requirements
• Poor/fluctuating oral intake
• Food preferences
• Physical and environmental factors
• Pain
• Inflammation
• Polypharmacy
• Digestion and absorption problems due to aging
種類
熱量
蛋白質
脂肪
膽固醇
鐵質
碎肉粥
480毫升
165卡路
里
6克
2克
23毫克
1.7毫克
魚湯
240毫升
76卡路
里
4.6克
4.6克
27.3毫克
微量
葡萄糖飲
品
300毫升
300卡路
里
微量
0
0
0
全脂奶
240毫升
150卡路
里
8克
8.2克
33.2毫克
0.122毫
克
營養奶
240毫升
250卡路
里
10克
4.6克
0
3.4毫克
Modified Diet (High Nutrition Puree)
• A high energy & high protein pureed mixed was designed by PWH Dietetics and Catering dept. • To maintain oral intake capacity as long as possible
• Support from the ward staff is essential Seven Steps Approach to stop Malnutrition
• Red Tray System
• Protected Meal Time
Choosing the Enteral Feeding Site
Can the GI tract be used?
No
Yes
Parenteral Nutrition
Tube feeding for more than 6 weeks?
No
Nasoenteric Tube
Yes
Enterostomy Tube
Risk for pulmonary aspiration?
No
Yes
No
Yes
Nasogastric Tube
Nasoduodenal
or nasojejunal tube
Gastrostomy
Jejunostomy
Complications of Enteral Feeding
• Electrolyte imbalance (46%)
• Hypo or Hyper K, Na, PO4, Ca
• Hyperglycemia (35%)
• Diarrhea (33%)
• >500ml every 8 hr or >3 stools/s for at least 2 consecutive days
• Only 20% of diarrhea related to formula
• Constipation (30%)
• Nausea & Vomiting (20%) Critical Care Med 2002
• Tube Clogging (13%)
Prof. Timothy Kwok, 2002, Medical Complication of Enteral Feeding In Frail Older People, CUHK
• Under & Overfeeding are common!
Complications of Enteral Feeding
• Pulmonary Aspiration
•
•
•
Risk factors: sedation, supine position, mal‐position of the feeding tube, mechanical ventilation, vomiting, bolus feeding delivery method, poor oral health, advanced age, and lack of nursing staff A.S.P.E.N 2009
No adequate powered studies demonstrated a relationship between aspiration pneumonia & GRV A.S.P.E.N 2009
Feeding protocol suggest not to stop feeding if GRV remain <200ml A.S.P.E.N 2006
• Refeeding Syndrome
•
•
•
•
•
High risk in malnourished & prolonged NPO patients
Caused by too aggressive feeding regime Low serum level of K, Mg, PO4 level
Insulin release which reduces salt and water excretion
Feeding should at 25% of estimated goal & advanced over 3‐5 d A.S.P.E.N 2009
Misconceptions on Enteral Feeding
• Rice Water
•
•
•
Studies proven effective in alleviating diarrhea (reduce stools/d)
Contains less than 40g CHO in 1L (<200Kcal/L)
May benefits patients resume feeding w/ long period of NPO
• ½ strength of Enteral formula
•
•
Lactose free and isotonic
Studies show not effective in solving diarrhea
• Oral formula for Tube feeding
•
Higher chance of developing GI discomfort
• Overfeeding w/ energy dense formula ( very common!!)
•
•
Ultracal at 300ml x 5/d = 1500Cal
Nepro at 300ml x 5/d = 3000Cal
Consequences of Overfeeding Special Nutrients
• Glutamine (EPUAP 2009)
• healing may be its function as a fuel & source for fibroblasts and epithelial cells needed for healing. • Safe maximum dose for glutamine 0.57g/Kg/BW
• Supplemental glutamine has not been shown to improve wound healing and more studies are needed • Arginine (EPUAP 2009)
• stimulates insulin secretion promotes the transport of amino acids into tissue cells and supports the formation of protein in the cells
• Maximum safe dosages of arginine have not been established
• Avoid using Arginine suppl. in sepsis patient due to the stimulation of nitric oxide (NO) production ‐ hypotension
• Not available in PN due to stability
• HMB (Beta‐Hydroxy beta‐methylbutyric acid )
• has been shown to inhibit breakdown of protein, such as muscle protein
• usually used in muscle building
• Further study to prove wound healing effect and safety dose
Special Nutrition Support
For Wound Healing
Formula
Route
Features
Limitation
Abound
Oral & Enteral
Contain arginine,
HMB, gultamine
Not nutritionally
complete,
Perative
Oral & Enteral
Contain Arginine,
Fair acceptance for
oral route, and high
Osmolarity
AlitraQ
Enteral
Elemental,
contains arginine
and glutamine
Expensive, not for oral
route, low fat and low
eletrolytes,
Some Common Formulas
Formula
Route
Features
Limitation
Ensure/Nutren
Optium & Fiber
1 Cal/ml
Oral
Economic, available every where, acceptable High Osmolarity,no fiber
taste
Fresubin 2 Kcal
Oral
Energy Dense, acceptable taste
High Osmolarity,no fiber
Ultracal
1 Cal/ml
Enteral
Good tolerance, adequate electrolytes, high
soluble fiber, cheap, high protein, isotonic
Monitor electrolytes level, use w/
caution in CRF, DM. may need
high vol. to meet requirement.
Osmolite HN
Enteral
Similar to Ultracal but no fiber
Similar to Ultracal
Osmolite, Isocal
1 Cal/ml
Enteral
Good tolerance, cheap, isotonic
Low electrolytes, low protein,
Glucerna or
Resource DM
1Cal/ml
Both
Lower CHO level,
High in fat
Compleat
1 Cal/ml
Both
Real food, high protein, moderate CHO
Expensive, chicken taste
Resource
Boosts Breeze
1Cal.ml,
Fresubin jucy
Oral
Fruit base formula,
High osmolarity, not a complete
formula
Isosource 1.5
Cal
Both
Energy dense, high protein, better fluid
control
Less tasty, expensive, dehydration
risk
Nutrition Support (Oral Formulas) Formula
Oral supplements
Comments
Acceptance
Normal
Ensure, Nutren , Enercal Plus
etc…
Low cost, better taste
Energy Dense
Fresubin 2kcal, Fresubin Jucy,
Fibersource HN, Resource Plus,
Isosource 1.5Cal, Enercal plus
1.5 kcal, …etc
Small gastric volume, Fluid
restriction, energy boosting,
lactose free,
Disease Specific
Supportan, Renlion, Gulcerna,
Nepro, Suplena, Pulmocare, Oral
Impact, Perative, Prosure…etc
Expensive, lactose free,
designed for diseases
Elemental
Peptamen, Peptamen Prebio,
Vital HN, AlitraQ
Expensive, best absorption,
Non-complete
Formula
Abound, Beneprotein, Benefiber,
Polycal…ect
Not a complete formula
**Most of the Enteral Formula are Lactose free
Nutrition Support (Tube Feeding)
Formula
Enteral supplements
Comments
Normal
Isocal, Ultracal, Osmolite,
Osmolite HN, Jevity…etc
Isotonic, cheap, may or may
not contain fiber
Energy Dense
Isosource 1.5Cal, Fibersource.
Small gastric volume, Fluid
restriction, energy boosting,
lactose free,
Disease Specific
Supportan, Renlion, Gulcerna,
Nepro, Suplena, Pulmocare,
Impact, Perative, Prosure…etc
expensive, lactose free,
designed for diseases,
hypertonic
Elemental
Peptamen, Peptamen Prebio,
Vital HN, AlitraQ…etc
Expensive, best absorption,
Non-complete Formula
Abound, Beneprotein, Benefiber,
Polycal…ect
Nutrient augmentation
**Most of the Enteral Formula are Lactose free
Formula choice, volume and rate depends on…
• Disease condition (DM, Hepatic, Kidney, COAD, GI problems, CA, palliative case, post or pre OT)
• Fluid Requirement (1kcal/ml or energy‐dense formula)
• Energy and Nutrients Requirements (Malnourished, Under or overweight, electrolytes)
• Tolerance (intermittent or pump)
• Laboratory results (nutrition status, RFT, LFT, Blood glucose)
• Availability • Price (Glucerna ~$19/can, Abound >$20/pack at retail price)
•“Dual‐Route Feeding in Pressure Sore Patients”
Possible Alternatives for Nutrition Augmentation
• PN is indicated and may allow adequate nutrition in patients who
cannot meet their nutritional requirements via the enteral route, and should be limited to situations when EN is contraindicated or poorly tolerated (C) • PN support should be instituted in the older person facing a period of starvation of more than 3 DAYS when oral or enteral nutrition is impossible, and when oral or enteral nutrition has been or is likely to be insufficient for more than 7‐10 DAYS. (C)
(ESPEN 2009)
Benefits of Dual Route Feeding
• Gut immunity can be stimulated by partial EN
• When tolerance to EN is limited by gut dysfunction,
• PN can deliver the required protein and calories, as well as some therapeutic nutrients (e.g. Glu, Fish oil) • Nutritional goal is easily achieved with patient
• comfort and safety, cosmetic concerns
• Consequences of inadequate nutrition are avoided
(Prof. J Asprer 2009)
Combination Feeding
(Enteral + Parenteral)
• Combination feeding for whose clinical status does not warrant full enteral nutrition
• Patients following a combination feeding regimen receive parenteral and enteral nutrition simultaneously
• Small amount of enteral nutrition will preserve the barrier function of the GI tract
• On going studies on this area
Nutrition Diagnosis
• Inadequate intake of energy and protein related to poor oral intake evidenced by:
• Mean energy intake 800kcal
• Mean protein intake 35g
• High risk of Malnutrition related to inadequate oral intake and abnormal level of nutrition indicators evidenced by:
• Inadequate intake according to estimated nutrient requirements
• Low serum alb & Hb, elevated CRP
Nutrition Intervention
• PPN plus oral nutrition support were given to all according to estimated requirements
• PPN (Kabiven Peripheral or Nutrilflex Lipid Peri)
• +/‐ additives (Vitalipid‐N, Soluvit‐N, Addamel‐N, Dipeptiven, Omegaven)
• Oral Nutrition Support
• Diet texture and perference modification
• Enteral formula (e.g. Abound, Perative, Glucerna, Ensure etc..)
• Fluid requirement • 30ml/kg BW or 1ml per 1kcal intake
Micronutrients
• Adjust according serum level (Na, K, Zn, PO4)
PN Complications
• Hyperglycemia
•
•
Adjust dextrose
Insulin therapy (added to PN)
•
•
Abrupt stopping of PN
1‐2 hr taper down
Life threatening
• hypoglycemia
• Electrolyte imbalance (Na, K, PO4)
• Azotemia (renal impairment)
• Mechanical
– phlebitis (K & Hypertonic solution)
– catheter occlusion
•
• Infection
• Calcium‐phosphate precipitate (reported 2 deaths)
•
•
Lower pH (add L‐cysteine & hydrochloride) and increase amino acids content to lower the risk
Use Calcium gluconate and Organic Phosphate
Nutrition Related Complications
• PNALD (Parenteral Nutrition Associated Liver Diseases) •
•
Elevated direct bilirubin concentrations (>2mg/dl, ~>33μmol), and in some cases progressing to hepatic failure
Studies show omega 3‐based formula prevent development of PNALD
•
•
Too aggressive nutrition therapy (full strength on the 1st day)
Hypo PO4, K, Mg,
• Overfeeding
•
•
•
•
Hyperglycemia
High TG
Increased CO2 production
Fluid overload (PPN vs. CPN)
Refeeding syndrome
• RF malaise, edema, muscle, weakness, hyperglycemia, and cardiac arrhythmia.
• Na retention and expansion of the extracellular
space, resulting in wt gain and cardiovascular demands, fluid shifts can result in cardiac failure, dehydration to fluid overload
• High Risk Group:
• wt lost > 10%, NPO for 7 to 10 day, prolong fasting, significant wt lost obese with gastric bypass surgery
• increase morbidity and mortality
Case # 1
•Grade IV pressure sore
•Male 59y, BW = 55kg (baseline Dec)
•Poor oral intake ~ 800 Cal/d (w/o oral supplements)
•Poor nutrition status – Ser alb 25, Hb 9.9, CRP 46.6
•Est. Energy and protein requirement:
•2100Kcal & 90g protein/d (for grade IV pressure sore patient)
(Oral Diet + Nutrition
Supplement*) x 75%
Oral Diet + Nutrition
Supplements + PPN
Energy (Cal)
~1500Cal/d
~2300Kcal/d
Protein (g)
~75g/d
~ 114g/d
% Nutrients Met
(Energy 80%, Protein 83%)
(Energy 110%, Protein 126%)
*Oral Nutrition Supplements:
Perative (300 Cal, argirine containing formula)
Resource Breeze (250 Cal, Orange flavor high protein supplement)
Case # 2
•
•
•
•
•
Grade IV pressure sore
Female 85y, BW = 45.8kg (baseline Dec)
Poor oral intake ~ 500 Cal/d (w/o oral supplements)
Poor nutrition status – Ser alb 29, Hb 8.6, CRP 30.1
Est. Energy and protein requirement: • 1600Cal & 70g protein/d (for grade IV pressure sore patient)
(Oral Diet + Nutrition
Supplement*) x
50%
Oral Diet + Nutrition
Supplements + PPN
Energy (Cal)
~800Cal/d
~1600Cal/d
Protein (g)
~50g/d
~89g/d
(13g from glutamine)
% Nutrients Met
(Energy 57%, Protein
70%)
(Energy 100%, Protein
128%)
*Oral Nutrition Supplements:
Perative (300 Cal, argirine containing formula)
Beneprotein 3 scoops/d (72Cal, 18g protein/d)
Case reviewed before discharge
• Case # 1 (4 weeks)
• BW 58.2kg (increased by 6%)
• Ser alb 33, CRP 3
• Oral intake improved ~ 1800Cal/d
• Case # 2 (2 weeks)
• Ser alb 35, Hb 11.1, CRP 4.8
• BW nil
• Oral intake improved (home diet taken)
Our Review
• A retrospective review
• 11 Elderly patients Severe pressure ulcer ;Stage 3 and Stage 4 (National Pressure Ulcer Advisory Panel, 1989)
• Referred to dietitian for nutrition support and further referred for Dual Route nutrition augmentation
• Objective: • To see any clinical improvement with PPN in additional to the conventional treatment.
• To see any relationship between albumin/CRP and PPN.
• To see any relationship before and after PPN supplement.
Exclusion Criteria 1. Lack of peripheral venous access
2. Diabetic patients with poor glycaemic Control
3. Terminal stage of illness 4. Severe demented patients;
5. Non‐cooperative patient
Average increase in energy intake and protein intake among the each patient
Protein Intake Change
Energy Intake Changes
kcal
gm
1800
80
1600
70
1400
60
1200
PPN+oral 1000
supplement
800
50
Pre Energy
Post Energy
40
PPN+oral supplement
Pre Prot
Post Prot
30
600
400
20
200
10
0
0
735 kcal increase
38g increase
Results
• 11 patients were retreived; 3 male and 8 female • Average age: 79.9+/‐7.8
• Mean Alb significantly increased from 25 to 29.9 mmol/l (p=0.022).
• Mean CRP were decreased significantly from 126.3‐39.5mg/l (p=0.017).
• Zero mortality during study period
What is interesting!
• Patients increase desire to eat during and after Dual route feeding
• Nutrients Recommended level for wound patients may not be adequate enough for some sever pressure ulcer patients
• A win‐win‐win situation (all patties are happy)
• Decrease use of antibiotic and dressing time The lady, before
After debridement, before PPN
During PPN
80 year‐old Gentleman
Multiple Wounds
After 23 Days Dual Route feeding
PN: Types of Infusion
• Continuous (24hr)
• Total volume of formula is administered over a 24 hour period
• Hyperinsulinemia – fat deposition in the liver increase liver
complications
• Cyclic (8-12hr)
• Volume is administered in one period, with infusion adjustments
and a period of rest
• Reduce liver enzyme and lower chance of PNALD
• Selection of infusion type depends on patient’s condition
• Use a parenteral infusion pump
Common 3‐in‐1 PN and additives in HA
• Smof Kabiven (CPN)
• Smof Kabiven Peripheral (PPN)
• Nutriflex Lipid Special (CPN)
• Nutriflex Lipid Peri (PPN)
• Oilclinomel (CPN & PPN)
• Dipeptiven – glutamine solution
• Soluvit N – water soluble vitamins
• Vitalipid N – Fat vitamins
• Addamel N – trace elements
• Omegaven – Fish oil for PN
• NaCl soluition (23.4% ort 5.85%)
Limitations……
• No control group of patients
• Number of patients in the study is small
• Many confounders such as wound infection, comorbidities, different treatments, etc.
• Need better wound size measurement
• Need a local clinical protocol PN Complications
• PNALD (Parenteral Nutrition Associated Liver Diseases) • Elevated direct bilirubin concentrations (>2mg/dl, ~>33ummol), and in some cases progressing to hepatic failure
• Studies show omega 3 based formula prevent development of PNALD Paed SBD
• Too aggressive nutrition therapy (full strength on the 1st day)
• Hypo PO4, K, Mg,
• Overfeeding
• Hyperglycemia
• High TG
• Increase CO2 production
• Fluid overload (PPN vs. CPN)
• GI bacteria translocation & GI Atrophy
Refeeding syndrome
• RF malaise, edema, muscle, weakness, hyperglycemia, and cardiac arrhythmia.
• Na retention and expansion of the extracellular
space, resulting in wt gain and cardiovascular demands, fluid shifts can result in cardiac failure, dehydration to fluid overload
• High Risk Group:
• wt lost > 10%, NPO for 7 to 10 day, prolong fasting, significant wt lost obese with gastric bypass surgery
• increase morbidity and mortality
Estimated Costing
• PPN ~ HK$200‐250/d (assume 1 bag/d)
• Additives ~ HK$110/d (all three)
• Dipeptiven HK$250/bottle
• Hospital diet ~ HK$20‐25/d
• Enteral nutrition ~ HK$5‐35/pack
• Estimated total nutrition cost from HK$585 – 660/d
• (R/T feeding ~ HK$20 – 150/d)
Recommendation
• Protocol for nutrition in wound management
• Multidiscipline approach (doctor, nurse, dietitian, Pharmacist)
• Patient centered care
• Individualized (tailor made) nutrition care plan
• Closely monitor (safety, complication, ethical concerns)
• Attachment • Local study!
Special Thanks
Mr. Gordon CHEUNG
President of HKNA
Prof. HUNG Leung Kim
Head of Dept. of O&T, CUHK
Dr. David DAI
Geriatric Consultant, Prince of Wales Hospital
Dr. LIU Kin Wah
Geriatric Associate Consultant, Queen Mary Hospital
Parenteral Nutrition for Adult (NTEC)
Thank you
WhatsApp
9410 7442