EAL

Recommendations Summary

SCI: Assessment of Nutritional Needs for Pressure Ulcers 2009

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

Recommendation(s)
SCI: Assessment: Energy Needs For Persons with Spinal Cord Injury with Pressure Ulcers

If a person with spinal cord injury has a pressure ulcer, the registered dietitian should measure energy needs by indirect calorimetry (IC). If indirect calorimetry is not available, any of the following predictive equations may be used to calculate energy needs :
- 30kcal to 40kcal per kg of body weight per day
- Harris-Benedict times stress factor (1.2 for stage II ulcer, 1.5 for stage III and IV ulcers).
No evidence currently exists to suggest that any one of the above predictive equations is superior to the others.

Persons with spinal cord injury with pressure ulcers have higher energy needs than persons with spinal cord injury who have similar levels of injury and no pressure ulcers. Evidence suggests that additional energy is needed for optimal healing of pressure ulcers.

Rating: Consensus
Conditional

SCI: Assessment: Protein Needs For Persons with Spinal Cord Injury with Pressure Ulcers

If a person with spinal cord injury has a pressure ulcer, the registered dietitian should calculate protein needs as follows:
- 1.2g to 1.5g of protein per kg body weight per day (Stage II pressure ulcers)
- 1.5g to 2.0g of protein per kg body weight per day (Stage III and IV pressure ulcers).
Persons with spinal cord injury with pressure ulcers have higher protein needs than persons with spinal cord injury who have similar levels of injury and no pressure ulcers. Evidence suggests that additional protein is needed for optimal healing of pressure ulcers.
- Arginine and its relationship to wound healing has been researched for over 30 years, primarily in animal models. Clear and definitive guidelines for its safe and effective use have yet to be established.
- Glutamine should not be routinely provided to all patients with wounds due to insufficient data.
Rating: Consensus
Conditional

SCI: Assessment: Fluid Needs for Persons with Spinal Cord Injury with Pressure Ulcers

If a person with spinal cord injury has a pressure ulcer, the registered dietitian should assess hydration status to determine fluid needs. Assessment of hydration status includes evaluation of parameters such as input and output, urine color, skin turgor, BUN and serum sodium. Increased fluid losses may result from the evaporation of fluids from a severe pressure ulcer, draining or open wounds, fever or the use of an air-fluidized bed. Current fluid recommendations are based on guidelines for the non-SCI population.
- Normal requirement: 30ml to 40ml per kg
- Minimum of 1.0ml per kcal per day
- 10ml to 15ml per kg additional fluids may be required with the use of air fluidized beds set at a high temperature (more than 31º to 34ºC or more than 88º to 93ºF)
  - Fluid loss includes evaporation from open wounds, wound drainage and fever
  - These guidelines are only a general indication of insensible water loss; the registered dietitian will need to monitor other parameters of hydration status.
Rating: Consensus
Conditional

SCI: Assessment: Micronutrient Needs for Persons with SCI with Pressure Ulcers

If a person with spinal cord injury has a pressure ulcer, the registered dietitian should recommend a daily vitamin and mineral supplement that meets no more than 100% of the RDA.

Certain micronutrients play a role in the process of wound healing; however, the optimal nutrient intake is not known at this time. Few rigorous scientific studies exist in this area, even for the non-SCI population. Therefore, comprehensive evidence-based practice guidelines are not developed for micronutrient needs.

If a person with spinal cord injury has a pressure ulcer and has a suspected or documented micronutrient deficiency, the registered dietitian should provide additional supplementation. Caution should be used when supplementing greater than the Tolerable Upper Intake Level (UL). The dietitian should re-evaluate the need for micronutrient supplementation every seven to 10 days.

Vitamin A

Vitamin A deficiency results in impaired wound healing and alteration in immune function that may increase the likelihood of wound infections. Documented recommendations for amount of Vitamin A for enhanced wound healing in injured patients is 10, 000 IU to 50, 000 IU per day and 10, 000 IU IV for moderate-severely injured patients or malnourished patients for a limit of 10 days. For patients receiving steroids, 10, 000 IU to 15, 000 IU for one week has been recommended to counteract the anti-inflammatory effects of steroids. Vitamin A supplementation should be implemented cautiously and judiciously because of potential toxicity.

Additional research is needed to confirm optimal dosage.

Vitamin C

Vitamin C deficiency has been associated with delayed wound healing. In patients with Vitamin C deficiency, supplementation has been shown to enhance wound healing. High doses of Vitamin C for healing chronic wounds is widely recommended in the literature. The Agency for Health Care Research and Quality recommends 100mg to 200mg per day of Vitamin C for Stage I and II pressure ulcers and 1, 000mg to 2, 000mg per day of Vitamin C for Stage III and IV pressure ulcers.

Additional research is needed to confirm optimal dosage.

Vitamin E

The effect of Vitamin E in healing acute and chronic wounds is controversial. Further research is needed in humans with controlled randomized trials to determine risks and benefits of various doses of Vitamin E and the effect on healing.

Zinc

Zinc deficiency is associated with delayed wound healing due to a decrease in collagen and protein synthesis and impaired immune competence. Replacement therapy guidelines have not been well defined in the literature. ZnSo4 220mg (50mg elemental Zinc) twice per day is recommended as a standard adult oral replacement. High-dose supplementation of zinc should be limited to two to three weeks. Dosage should be individualized according to zinc status and metabolic demands.

Iron

Anemia assessed by hemoglobin and hematocrit levels reduces oxygen supply to tissues, thus impairing healing of pressure ulcers. If low hemoglobin concentration is due to iron deficiency anemia, it may be a factor in tissue hypoxia and impaired wound healing. Supplementation should be provided as indicated to correct iron deficiency anemia.

Rating: Consensus
Conditional
- Risks/Harms of Implementing This Recommendation
  - Provision of nutrition support, including enteral or parenteral nutrition, to nutritionally compromised patients with spinal cord injuries may be associated with patient complications including, but not limited to:
    
    Aspiration
    
    Infections, including catheter-related infections
    
    Metabolic complications resulting from under- or overfeeding
    
    Gastrointestinal complications, including diarrhea.
  - Use of predictive equations rather than measured energy expenditure may result in under- or overfeeding persons with SCI and may lead to metabolic complications with subsequent poor outcomes such as obesity, pressure ulcer development, decreased ability to perform ADLs and transfers, heart disease and diabetes
  - Additional consideration should be given to fluid intake in patients with conditions in which fluid should be restricted such as renal disease, heart failure and bladder management programs
  - The protein needs recommendation may be contraindicated in persons with spinal cord injury who have concurrent hepatic or renal dysfunction
  - Vitamin A: Caution that supplementation of Vitamin A, even at the lower range of the recommendations, is not strongly justified. Systematic Vitamin A could potentially reactivate the inflammatory reaction against which the steroid use was aimed. The benefits of high doses should be weighed against the potential risk of toxicity. Use of a water soluble form of Vitamin A should be considered in cases of fat malabsorption.
  - Vitamin C: Use caution with higher doses of vitamin C in those with renal failure due to the possibility of renal oxalate stone formation. Adverse effects such as nausea, abdominal cramping and diarrhea may occur with increased doses.
  - Vitamin E: Use caution when supplementing with Vitamin E, as there is evidence from animal studies that vitamin E may delay wound healing by impairing collagen synthesis
  - Zinc: High-dose supplementation can adversely affect copper status, immune response and lipid profiles and may cause GI side effects. Some authors have suggested that high-dose supplementation should be limited to two to three weeks to minimize the risk of adverse effects unless justified by ongoing losses. Parenteral dose of zinc is less than oral and enteral recommendations due to differences in bioavailability.
- Conditions of Application
  - This recommendation applies to persons with spinal cord injury with pressure ulcers
  - Actual weight should be used in calculating energy and protein needs; however, the patient should be closely monitored for signs and symptoms of overfeeding or underfeeding or of substrate overload
  - Decreased albumin and transthyretin (prealbumin) are often interpreted as indicators of malnutrition. However, albumin and prealbumin are also inversely influenced by inflammatory and stress response. These visceral proteins should be interpreted, keeping in mind the patient's total clinical status. Use of C-reactive protein, a protein that increases with stress, is useful in interpreting whether albumin and prealbumin are being affected or decreased by inflammation and stress. The role of albumin as a nutrition indicator in persons with spinal cord injury will be addressed systematically in scheduled updates to this guideline. This recommendation applies to patients in the acute phase of spinal cord injury.
  - Due to the metabolic response to illness, levels of vitamin A, vitamin C and zinc may be affected by the stress response and not be indicative of nutritional status.
- Potential Costs Associated with Application
  - Significant organizational costs are associated with the treatment of pressure ulcers in persons with spinal cord injury, including the provision of staff, equipment, supplies, blood work, facilities, nutritional supplements and nutrition support required for appropriate care.
  - Organizational expenses incurred as a result of treating pressure ulcers may be reduced by the provision of adequate nutrition care, as appropriate nutrition care may reduce healing time and thus reduce organizational costs.
- Recommendation Narrative
  - One clinical practice guideline provided evidence-based expert recommendations regarding nutrition care for pressure ulcers, including recommendations for assessment of energy, protein and micronutrient needs and monitoring of nutrition and hydration status (Consortium for Spinal Cord Medicine, 2000)
  - Two nutrition support textbooks provided general recommendations for nutrition care in wound healing, including recommendations for micronutrient intake (ASPEN Nutrition Support Manual, 2005; ASPEN Nutrition Support Core Curriculum, 2007; ADA Nutrition Care Manual, Baranski and Ayello, 2008)
  - See 'Citations Not Used in Evidence Analysis' for other works consulted.
- Recommendation Strength Rationale
  - Rating is based on expert consensus, clinical guidelines and textbooks
  - Few to no high-quality studies of strong design are available at this time.
- Minority Opinions
  Consensus reached.

Supporting Evidence
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
- References
- References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
  - Pressure ulcer prevention and treatment following spinal cord injury: A clinical practice guideline for health care professionals. Consortium for Spinal Cord Medicine, Paralyzed Veterans of America. 2000.
  - ASPEN 2005 Nutrition Support Manual. American Society for Parenteral and Enteral Nutrition. 2005.
  - ASPEN 2007 Nutrition Support Core Curriculum. American Society for Parenteral and Enteral Nutrition. 2007.
  - Nutrients and wound healing: Still searching for the magic bullet. Nutrition in Clinical Practice. 2005 June; 20: 331-347.
  - ADA Nutrition Care Manual. Chicago, IL: ADA; 2008.
  - 5 Million Lives Campaign. Available at: http://www.ihi.org/IHI/Programs/Campaign/.
  - Baranski S, Ayello EA. Wound care essentials: Practice principles. Philadelphia: Lippincott Williams and Wilkins; 2008.