Impact of a Nutritional Formula Enriched in Fish Oil and Micronutrients on Pressure Ulcers in Critical Care Patients

Table 1.  Composition of selected nutrients in 100 mL of the control and study formulas

Nutrient	Control formulas		Study formulas
	Enterala	Parenteralb	Enteralc	Parenterald
Carbohydrates, g	15.4	14.1	10.5	14.1
Fat, g	3.5	4.0	9.4	4.0
Protein, g	4.4	3.4	6.2	3.4
Eicosapentaenoic acid, g	0	0	0.46	0.125–0.282
Docosahexaenoic acid, g	0	0	0	0.144–0.309
γ-Linoleic acid, g	0	0	0.4	0
Vitamin C, mg	15.7–22.5	125	850	125
Vitamin E, IU	2.3–3.4	1.12	32.0	1.12
Vitamin A, IU	375.9	350.0	667.8e	350.0
Copper, mg/L	1–1.5	0.4	2.2	0.4
Manganese, mg/L	2.6–3.7	0.1	5.3	0.1
Zinc, mg/L	16.8	1	23.9	1

^aJevity (Abbott Nutrition, Columbus, Ohio).
^bOliClinomel N6–990 E (Baxter Healthcare Ltd, Maurepas, France).
^cOxepa (Abbott Nutrition, Columbus, Ohio).
^dOliClinomel N6–990 E (Baxter Healthcare Ltd, Maurepas, France) and Omegaven (Fresenius Kabi, Bad Homburg, Germany).
^eSupplied by 5 mg of beta carotene.

Table 2.  Characteristics of patients in the study

Characteristica	Control group	Intervention group
No. of patients	20	20
Age, mean (SD), y	53.1 (19.3)	49.3 (20.7)
Sex, male/female	13/7	14/6
Body mass index,b mean (SD)	32.1 (9.9)	28.3 (4.8)
Hours in intensive care unit, mean (SD)	507.0 (217.8)	627.2 (340.9)
APACHE II score, mean (SD)	25.7 (7.0)	23.0 (6.7)
Diagnostic category
Medical	9	5
Trauma	8	11
Surgery	3	4

Abbreviation: APACHE, Acute Physiology and Chronic Health Evaluation.
^aNo significant differences were noted between the 2 groups for any characteristic.
^bCalculated as the weight in kilograms divided by the height in meters squared.

Table 3.  Subscores and scores on Pressure Ulcer Scale for Healing

		Score, mean (SD)
Variable	Day	Control group	Study group	P
Length x widtha	0	5.63 (1.76)	6.30 (2.00)	.07
	7	6.00 (1.85)	6.30 (2.62)
	14	6.63 (1.99)	6.10 (2.42)
	28	6.75 (2.25)	6.00 (2.79)
Exudate amountb	0	1.25 (0.46)	1.40 (0.96)	.02
	7	1.38 (0.74)	1.20 (0.78)
	14	1.50 (0.75)	1.20 (0.78)
	28	1.63 (0.74)	1.20 (0.79)
Tissue typec	0	2.38 (0.74)	2.60 (0.96)	.65
	7	2.38 (0.74)	2.50 (0.70)
	14	2.25 (0.70)	2.30 (0.82)
	28	2.38 (0.74)	2.30 (0.82)
Total scored	0	9.25 (2.12)	9.10 (2.84)	.02
	7	9.44 (2.60)	8.79 (3.39)
	14	9.67 (2.50)	9.19 (4.10)
	28	10.75 (3.41)	9.40 (3.72)

^aLength × width is defined by 0 points if 0 cm²,1 point if <0.3 cm², 2 points if 0.3–0.6 cm², 3 points if 0.7–1.0 cm², 4 points if 1.1–2 cm², 5 points if 2.1–3 cm², 6 points if 3.1–4 cm², 7 points if 4.1–8 cm², 8 points if 8.1–12 cm², 9 points if 12.1–24 cm², 10 points if >24 cm².
^bExudate amount is defined as follows: 0 if none, 1 if light, 2 if moderate, and 3 if heavy.
^cTissue type is defined as 0 points if closed,1 point if epithelial tissue is present, 2 points if granulation tissue is present, 3 if slough is present, and 4 if necrotic tissue is present.
^d P<.05, study vs control group as calculated by using repeated-measures analysis of variance.

Table 4.  Concentrations of C-reactive protein during the 14-day study period

	C-reactive protein, mg/L
Day	Control group	Study group
0	145 (90)	191 (104.4)
7	149 (81)	105a (85.6)
14	139 (62)	111.7b (97.8)

^aLength × width is defined by 0 points if 0 cm²,1 point if <0.3 cm², 2 points if 0.3–0.6 cm², 3 points if 0.7–1.0 cm², 4 points if 1.1–2 cm², 5 points if 2.1–3 cm², 6 points if 3.1–4 cm², 7 points if 4.1–8 cm², 8 points if 8.1–12 cm², 9 points if 12.1–24 cm², 10 points if >24 cm².
^bExudate amount is defined as follows: 0 if none, 1 if light, 2 if moderate, and 3 if heavy.
^cTissue type is defined as 0 points if closed,1 point if epithelial tissue is present, 2 points if granulation tissue is present, 3 if slough is present, and 4 if necrotic tissue is present.
^d P=.02, study vs control group as calculated by using repeated-measures analysis of variance.

Authors and Disclosures

By Miriam Theilla, RN, Betty Schwartz, PhD, Jonathan Cohen, MBBCh, FCP, Haim Shapiro, MD, Ronit Anbar, RD, and Pierre Singer, MD

Miriam Theilla is a senior nurse, General Intensive Care Department, Rabin Medical Center, Campus Beilinson, Petah Tikva, Israel, and nutrition nurse in charge, Institute for Nutrition Research, Rabin Medical Center, Petah Tikva, Israel. Betty Schwartz is the head of the faculty of nutrition and Robert H. Smith is a member of the faculty of agriculture, food, and environment, Hebrew University of Jerusalem, Israel. Jonathan Cohen is the associate director, General Intensive Care Department, Rabin Medical Center, Campus Beilinson, and senior lecturer at Tel Aviv University, Israel. Haim Shapiro is a researcher at the Institute for Nutrition Research, Rabin Medical Center, and Ronit Anbar is deputy of nutrition services, Rabin Medical Center, Campus Beilinson. Pierre Singer is the director, General Intensive Care Department, Rabin Medical Center, Campus Beilinson, and a professor of critical care, Tel Aviv University and Institute for Nutrition Research, Rabin Medical Center.

Financial Disclosures
None reported.

Corresponding author
Prof Pierre Singer, Dept General Intensive Care and Institute of Nutrition Research, Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel (e-mail: psinger@clalit.org.il).