Nutrition and Pressure Ulcer Healing

The Effectiveness of Nutritional Intervention(s) and the Treatment of Pressure Ulcers -- A Systematic Literature Review

Siang Choo T, Hayter M, Watson R
Int J Nurs Pract. 2013;19(Suppl 1):19-27

Pressure Ulcers and Nutrition

Pressure ulcers are both a financial and a quality burden to the healthcare system. The Centers for Medicare & Medicaid Services (CMS) considers stage 3 and 4 ulcers acquired while in the hospital to be "never events" and will not reimburse the costs associated with their treatment. Although the elderly, particularly those with poor nutritional status, have long been recognized to be at risk for the development of pressure ulcers, the role of nutrition in their management is unclear, as determined by a 2003 Cochrane review.^[1] The purpose of this study was to critically review the literature and attempt to determine whether nutritional therapy, and specifically what types of nutritional supplementation, enhances the healing of pressure ulcers.

Methods. Siang Choo, Hayter, and Watson searched databases for randomized controlled trials (RCTs) conducted since 2000, a time point chosen because the previous Cochrane review examined all studies published before that date. Studies were limited to those reported in English. There were no other limitations -- patient populations spanned all ages and both sexes and were conducted in any healthcare setting and with any degree of pressure ulcer. The intervention of interest was any enteral or parenteral nutritional supplementation or special diet. The primary outcomes were any measure of wound healing including time to complete healing, proportion of wound healed, or reduction in ulcer area. Secondary outcomes included patient care measures such as time spent on dressing changes, occurrence of infection, or use of antibiotics, and adverse events from supplementation.

Study Findings

A total of 6 RCTs were included, all conducted in developed countries (4 in Europe, 1 in the United States, 1 in Australia). The trials included a combined total of 352 patients ranging in age from 63 to 91 years. The period of nutritional intervention was 2-12 weeks, and several methods were used to determine patient outcome. Because of the heterogeneity of the RCTs, a meta-analysis could not be conducted. The 6 trials are summarized in the table.

Table. Systematic Review Summary^[2]

Trial	Duration	Patients	Intervention	Findings
1^[3]	8 weeks	N = 43 with stage 3-4 pressure ulcers	High-protein arginine diet vs controls	- Significant reduction in wound size in intervention group - Fewer dressings and less time spent on dressing changes
2^[4]	12 weeks	N = 28 with stage 2 pressure ulcers in long-term care	Nutritional supplements and 20% calories from protein vs standard nutrition	- Higher rate of healing in supplemented group - Reduced pressure ulcer area - Lower rate of infection - Less use of antibiotics
3^[5]	6 weeks	N = 160 with heel ulcers in hospitalized or outpatients	Ornithine alpha-ketoglutarate (OKG) supplements vs placebo	- No significant overall reduction in wound size - Smaller ulcers had greater size reduction in the OKG group
4^[6]	8 weeks	N = 89 with ≥ stage 2 pressure ulcers in long-term care	Nutritional supplements vs placebo	- Rate of healing almost twice as fast in supplement group
5^[7]	3 weeks	N = 16 hospitalized patients	High-protein diet supplemented with arginine, vitamin C, and zinc vs standard high-protein diet	- Improvement 2.5 times greater in supplement group
6^[8]	2 weeks	N = 16 with severe cognitive impairment hospitalized patients	Group 1-Standard hospital diet Group 2-Diet supplemented with protein Group 3-Diet supplemented with protein, arginine, vitamins, and trace elements	- More rapid healing in arginine group (no test for significance)

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