Prosource Nutritional Supplements Articles & Resources

Because his wounds exhibited little healing progress, the dietitian was asked to review Mr R's nutritional status.

Time to Intervene

The dietitian determines that Mr R is receiving adequate calories and fluids per his requirements and can to tolerate additional volume. His weekly weights are level and within the adjusted range for his amputation. However, his protein needs are not being met based on the status of his wound and his prealbumin level of 9 mg/dl (which indicates moderate depletion).

Protein is responsible for the synthesis of enzymes involved in wound healing and cell multiplication, as well as collagen and connective tissue synthesis. The current recommendation for protein intake for stressed patients ranges from to g/kg/day. Higher protein intakes are associated with improved wound healing in patients with pressure Although the optimum protein range has not been established, a range of to g/kg/day has been associated with wound Intake beyond g/kg/day can affect renal and hepatic

To meet Mr R's increased protein needs, the dietitian recommends a high-nitrogen, cnzyme-hydrolyzed, tryptophan-fortified collagen liquid protein that mixes well with the water flush, will not clog the feeding tube, and provides 15 grams of protein per ounce. As with other protein products, predigesting proteins facilitate absorption in the gastrointestinal tract, thus making the amino acids more bioavailable. One ounce of the liquid product twice daily provides the protein needed to meet Mr R's additional requirements.

The product contains the essential amino acids and is enriched with arginine at a level of grams/100 grams of protein and glutamine at 11 grams/100 grams of protein. Arginine is a substrate for nitric acid and regulates nucleic acid synthesis. Nitric acid production activates wound macrophages, which are rich sources of growth factors, cytokines, bioactive lipid products, and proteolytic enzymes necessary for the healing

The increased level of arginine promotes its own conversion to ornithine, a precursor to prolinc that is incorporated into After 3 weeks of additional protein intake, Mr R's wounds begin to decrease in size and demonstrate signs of healing.

Role of Modular Protein

The need to increase protein without increasing total caloric intake is often a challenge for the dietitian or health care professional. In addition to patients like Mr R, obese patients are ideal candidates for modular protein. Although they may need increased protein, they should not receive the high-calorie supplements designed for undernourished patients with wounds.

Clinicians should become familiar with the various types of powdered and liquid supplements that provide protein and moderate calories to patients with wounds. Factors to consider when selecting such supplements include:

* protein source

* grams of protein per serving

* number of servings to meet protein requirement

* taste, if taken orally

* ease in mixing

* ability to mix into hot/cold products

* cost per gram of protein.

Modular protein products may have a soy, whey, casein, or egg white composition. Or they may have a hydrolyzed collagen and casein base or a hydrolyzed collagen base fortified with tryptophan, which is considered a high-quality protein that contains the essential amino acids required for growth and wound healing. Most commercial powdered products provide 5 to 7 grams of protein per serving, versus 10 to 15 grams of protein per ounce of the liquid products.

To evaluate the available products, dietitians should meet with their facility's wound care team, as well as with wound care patients. Results can be incorporated into a facility's nutrition protocol for wound healing, which would include monitoring the total nitrogen intake and the hydration status. Commercial products currently on the market include ArgiMent (National Nutrition Inc), Arginaid and Beneprotein (Novartis), Hi-ProCal (Hormel), ProMod (Ross/Abbott), ProSource (National Nutrition Inc), ProSure (Ross/Abbott), and Pro-Stat101 (Medical Nutrition, Inc).

References

1. Chernoff R, Milton K, Lipschitz E, et al. The effect of a high protein formula on decubitus ulcer healing in long-term tube fed institutionalized patients. JADA 1990; Oct suppl;A-130.

2. Breslow RA, Hallfrisch J, Guy DG, Crawley B, Goldberg AP. The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc 1993;41:357-62.

3. Yarkony GM. Pressure ulcers: a review. Arch Phys Med Rehabil 1994;75:908-17.

4. Kiy AM. Nutrition in wound healing. A bio-psychosocial perspective. Nurs Clin North Am 1997;32:849-62.

5. Steed D. The role of growth factors in wound healing. Surg Clin North Am 1997;77:575-86.

6. Martin P. Wound healing-aiming for perfect skin regeneration. Science 1997;276:75-81.

7. Slavin J. Wound healing pathophysiology. Surgery 1999;17(4):I-V.

8. Albina JE, Mills CD, Barbul A, et al. Arginine metabolism in wounds. Am J Physiol 1988;254 (4 Pt 1):E459-67.

9. Kirk S, Barbul A. Role of arginine in trauma, sepsis, and immunity. JPEN J Parenter Enteral Nutr1990;14(5Suppl):226S-29S.

10. Schaffer MR, Tantry U, Ahrendt GM, Wasserkrug HL, Barbul A. Acute protein-calorie malnutrition impairs wound healing: a possible role of decreased wound nitric oxide synthesis. J Am Coll Surg 1997;184:37-43.

Mary Ellen Posthauer, RD, CD, LD

Mary Ellen Posthauer, RD, CD, LD, is a registered and licensed dietitian and CEO of MEP Healthcare Dietary Services, lnc, in Evansville, IN. Her company provides clinical and food service management to long-term-care facilities and group homes. She is a member of the National Pressure Ulcer Advisory Panel. The author has disclosed that she is on the speaker's bureau for Novartis Laboratories. The case presented in this article resembles many patients who have protein needs that require supplemental protein without additional calories. This case study does not represent a specific patient.