Tissue repair

Tissue repair is an intricate process in which the skin (or another organ-tissue) repairs itself after accidental injury, disease or surgical intervention. Wound healing involves the activity of a complex network of blood cells, tissue types, cytokines, and growth factors which results in increased cellular activity and causes an intensified metabolic demand for nutrients. The overall health and nutritional status of the patient influences the outcome of the damaged tissue: the combination of a nutrient-rich diet and supplementation, especially in proteins and energy, creates an ideal physiologic environment for healing. Several nutritional cofactors involved in tissue regeneration have been identified such as vitamins A, C, and E, zinc, arginine, glutamine, and glucosamine.
What are pressure ulcers?

A pressure ulcer, also called bedsore, is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear or friction1.
Bedsores are painful, costly, and represent a major burden of sickness and reduced quality of life for patients suffering from them2-4. They increase morbidity and mortality in hospitalized patients5,6.
A survey of the European Pressure Ulcer Advisory Panel (EPUAP) found an overall prevalence of bedsores of 18.1%7 in hospitalized patients in 5 European countries. As for the United States, in 2001, the National Pressure Ulcer Advisory Panel (NPUAP) estimated that pressure ulcer prevalence in hospitals was 15%8.

Risk factors of pressure ulcers

Bedsores are often preventable complications that threaten many individuals in hospitals, nursing homes, and home care, especially elderly people with disabilities.
Unintentional weight loss, protein-energy malnutrition (PEM), and dehydration are known risk factors for pressure ulcer development9.
Acute or chronic diseases, as well as post-surgical intervention or hip fracture, are also risk factors for bedsores.

Management of pressure ulcers

In addition to their usual diet, high-protein mixed nutritional oral supplements are recommended for individuals with nutritional risk and risk of pressure ulcers. There are reports that bedsores can be managed by high-protein, specific amino acids such as glutamine and L-arginine, vitamin C, vitamin A and zinc intake10-12.
The adequate daily protein intake should be 1.2-1.5g / kg body weight; regarding energy, the daily intake should be 30-40kcal/kg body weight13.

  • L-arginine is considered a semi-essential aminoacid and plays an important role in the prevention and treatment of pressure ulcers. Besides stimulation of protein synthesis, arginine is involved with cell signalling through the production of nitric oxide and cell proliferation through its metabolism to polyamines, promoting collagen synthesis and deposition, which helps to increase wound strength, and improving T-lymphocyte function, which strengthens the immune system.
  • Zinc and vitamin C are two of the most commonly used nutrients in dietary interventions, as both of these nutrients play an important role in collagen synthesis. However, the scientific evidence of the effects of these nutrients supplemented alone hasn’t been sufficiently proven 11. Therefore, usually they are added to supplements together with L-arginine.
  • Vitamin A enhances early inflammatory phase of wound healing, supports epithelial cell differentiation, improves localization and stimulation of immune response14.
  • Skincare can also protect the skin from the development of pressure ulcers, as well as body repositioning and use of specific support surfaces.

Laboratoires Grand Fontaine offers a complete range of nutritional options adapted to the patient’s condition:

References
1 National Pressure Ulcer Advisory Panel & European Pressure Ulcer Advisory Panel (NPUAP). Pressure Ulcer Treatment. Technical report. 2009.
2 Franks PJ, Moffatt CJ, Ellison DA, Connolly M, Fielden S, Groarke L, et al. Venous ulceration: A randomized trial of two bandage systems. Phlebology. 1999;14:95-9.
3Hopkins A, Dealey C, Bale S, Defloor T, Worboys F. Patients’ stories of living with a pressure ulcer. Journal of Advanced Nursing. 2006;56(4):345-53.
4 Nixon J, Nelson EA, Cranny G, Iglesias CP, Hawkins K, Cullum NA, et al. Pressure-relieving support surfaces: a randomized evaluation. Health Technology Assessment 2006;10(22):iii-x, 1.
5 Allman RM, Goode PS, Burst N, Bartolucci AA, Thomas DR. Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. Advanced Wound Care. 1999;12(1):22-30.
6 Ducker A. Pressure ulcers: assessment, prevention, and compliance. Case Manager. 2002;13(4)61-4.
7 Vanderwee K, Clark M, Dealey C, Gunninberg L, Defloor T. Pressure ulcer prevalence in Europe: a pilot study. Journal of Evaluation in Clinical Practice 2007;13(2):227-32.
8 National Pressure Ulcer Advisory Panel. Pressure ulcers in America: prevalence, incidence, and implications for the future. Cuddigan J, Ayello E, Sussman C, editors. Reston, VA: NPUAP; 2001.
9 Lyder C, Yu C, Stevenson D, Mangat R, Empleo-Frazier O, Emerling J, McKay J. Validating the Braden Scale for the prediction of pressure ulcer risk in blacks and Latino/Hispanic elders: a pilot study. Ostomy Wound Management. 1998;44(suppl3A):42S-49S.
10 Schols JM, Heyman H, Meijer EP. Nutritional support in the treatment and prevention of pressure ulcers: an overview of studies with an arginine enriched oral nutritional supplement. J Tissue Viability. 2009 Aug;18(3):72-9.
11 D. De Luis, R. Aller. Revisión sistemática del soporte nutricional en las úlceras por presión. AN. MED. INTERNA (Madrid). Vol. 24, N.º 7, pp. 342-345, 2007.
12 Stratton RJ, Ek AC, Engfer M, Moore Z, Rigby P, Wolfe R, Elia M. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev. 2005 Aug;4(3):422-50.
13 Haute autorité de santé. Stratégie de prise en charge en cas de dénutrition protéino-énergétique chez la personne âgée. Avril 2007.
14 MacKay D, Miller AL. Nutritional support for wound healing. Alternative Medicine Review. 2003 Nov;8(4):359-77.

Wound healing is a growing health burden across the globe. Wound infections increase dependency and hospital admissions. People suffering from chronic wounds have a reduced quality of life and various metabolic complications.
Diabetic foot wounds are the most common chronic wounds (i.e. they take more than 4-6 weeks to heal) in the world.

What are the risk factors of delayed wound healing?

  • Being more than 65 years old
  • Protein-energy malnutrition
  • Dehydration
  • Chronic diseases, especially diabetes mellitus that causes ulcers on legs and feet
  • Immobility
  • Cancer
  • Hip fracture

How to manage wound healing?

Wound healing is an energy-intensive, anabolic process that demands optimal food intake. Medical nutrition therapy includes1:

  • Energy intake of 30 to 35 kcal/kg body weight.
    The achievement of the optimal energy requirements is the most important component of nutritional care for wound healing. Without optimum calorie intake, there will not be enough protein available to promote wound healing (since the proteins will be used as energy), and vitamin and mineral intake will most likely be suboptimal.
  • Protein intake of 1.25 to 1.5 g/kg body weight. Proteins are essential to maintain and repair lean body mass and therefore have a crucial effect on wound healing. As a consequence, adequate protein status is a key factor for recovery in the process of wound healing2.
  • L-glutamine supplementation:
    Glutamine is a conditionally-essential amino acid in stress, injury and critically ill patients, because of its important role in the immune system, antioxidative responses and cell proliferation. Glutamine is also a major metabolic fuel for the small intestine cells to maintain digestive function and protect mucosal integrity3,4. Because optimal functioning of fibroblasts and inflammatory cells is paramount to the healing process, glutamine is also a necessary component of the process of tissue repair5. Glutamine supplementation has been shown to be beneficial in treating complications due to cancer treatment. It protects against radiation-induced mucositis, may prevent neurotoxicity of some drugs and reduces the severity of the immunosuppressive effect induced by chemotherapy.
  • L-arginine supplementation: Arginine is also a conditionally essential aminoacid that intervenes in multiple functions, such as promoting nitric oxide and polyamines synthesis, enhancing wound healing process and stimulating of immune responses6,7,8.
  • Balanced diet that meets the recommended Dietary Allowances for all vitamins and minerals.
  • 30 ml fluid/kg body weight to prevent dehydration, as increased amounts of fluids may be necessary in the case of elevated temperature, vomiting, profuse sweating, diarrhea, or heavily draining wounds.

Laboratoires Grand Fontaine offers a complete range of nutritional options adapted to the patient’s condition

References
1 Dorner B, Posthauer ME, Thomas D. The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel white paper. 2009
2 Ord H. Nutritional support for patients with infected wounds. British Journal of Nursing. 2007 Nov 22-Dec 12;16(21):1346-8, 1350-2
3 Newsholme P. Why is L-glutamine metabolism important to cells of the immune system in health, post-injury, surgery or infection? Journal of Nutrition. 2001;131:2515S-2522S.
4 Souba WW. Glutamine, fibroblasts, and wounds. Glutamine Physiology, Biochemistry, and Nutrition in Critical Illness. Austin, TX: R.G. Landes Company.1992:67-69
5 MacKay D, Miller AL. Nutritional support for wound healing. Alternative Medicine Review. 2003 Nov;8(4):359-77.
6 Arana V. Healing of diabetic foot ulcers in L-arginine-treated patients. Biomedicine & Pharmacotherapy. 2004.
7 Stechmiller JK, Childress B, Cowan L. Arginine supplementation and wound healing.  Nutr Clin Pract. 2005 Feb;20(1):52-61.
8 Leigh B, Desneves K, Rafferty J, Pearce L, King S, Woodward MC, Brown D, Martin R, Crowe TC. The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers. J Wound Care. 2012 Mar;21(3):150-6.

According to the World Health Organization (WHO), burns are the fourth most common type of trauma worldwide, after traffic accidents, falls, and interpersonal violence 1.
Burns lead to an intense inflammatory state, requiring a highly monitored nutritional support.

What are the consequences of burns?

Major burns produce a variety of metabolic and nutritional consequences. The patient’s metabolic rate is often doubled, and caloric demand can reach 3000-5000 calories per day.
Skeletal and visceral proteins are mobilized to meet the increased nutritional demand. As a consequence, patients with burns have a negative nitrogen balance, and their immunologic functions decrease.
Patients with burns have a high exposure to complications in the wound healing process associated with protein-energy malnutrition.

Nutritional management of burns

Careful nutritional support is essential. The feeding of supplements is advisable for patients unable to reach their recommended calorie and protein requirements through regular oral diet. An increase in protein intake may be beneficial2.
Specific amino-acid supplementation, with glutamine and arginine, is appropriate.

Glutamine is a non-essential amino acid that can become a conditionally essential amino acid in certain circumstances, including tissue injury and critically ill patients. It is used by fibroblasts and immune cells within the wound and systemically for proliferation and as a source of energy3,4. Because optimal functioning of these cells is paramount to the healing process and immune response, glutamine is a necessary component of the process of tissue repair and infection protection5. Clinical benefits of glutamine supplementation in burn patients include reductions in infection rate, length of stay, costs, and mortality6,7.

Laboratoires Grand Fontaine offers a complete range of nutritional options adapted to the patient’s condition:

References
1 World Health Organization. The Global Burden of Disease: 2004 Update. World Health Organization, Geneva. 2008.
2 Prelack K, Dylewski M, Sheridan RL. Practical guidelines for nutritional management of burn injury and recovery. Burns. 2007 Feb;33(1):14-24. Epub 2006 Nov 20.
3 Newsholme P. Why is L-glutamine metabolism important to cells of the immune system in health, post-injury, surgery or infection? Journal of Nutrition. 2001;131:2515S-2522S.
4 Souba WW. Glutamine, fibroblasts, and wounds. Glutamine Physiology, Biochemistry, and Nutrition in Critical Illness. Austin, TX: R.G. Landes Company. 1992:67-69.
5 MacKay D, Miller AL. Nutritional support for wound healing. Alternative Medicine Review. 2003 Nov;8(4):359-77
6 Garrel D, Patenaude J, Nedelec B, et al. Decreased mortality and infectious morbidity in adult burn patients given enteral glutamine supplements: a prospective, controlled, randomized clinical trial. Critical Care Medicine. 2003;31:2444–9.
7 Wischmeyer PE, Lynch J, Liedel J, et al. Glutamine administration reduces gram-negative bacteremia in severely burned patients: a prospective, randomized, double-blind trial versus isonitrogenous control. Critical Care Medicine. 2001;29:2075–80.

Surgery leads to intense metabolic stress, even in healthy people. It affects many body functions with potentially serious complications, especially in frail patients such as the elderly. In addition, the rate of surgical procedures in the older population is rising.

What are the consequences of post-surgery?

Weight loss is the most common consequence of surgery. Comorbidities and reduction in physiological reserve are ordinary outcomes of surgery.
Surgery can also induce nausea, vomiting, and malabsorption, which delay recovery by accentuating protein-energy malnutrition.

Nutritional management of post-surgical patients

Post-operative nutritional support enhances recovery after surgery. On the other hand, malnutrition is a risk factor for post-operative morbidity and mortality. Proper nutritional management after surgery includes:

  • Increased protein and energy intake, as wound healing is an energy-intensive, anabolic process. The adequate daily protein intake is 0.8g/kg body weight.
  • Micronutrient intake such as vitamin A, vitamin C, zinc, glutamine, arginine and glucosamine.

Laboratoires Grand Fontaine offers a complete range of nutritional options adapted to the patient’s condition:

Food for special medical purposes.
Use under medical supervision.