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What you need to know about chronic wound treatment [flow chart]

A Manitoba dietitian shares her experience researching the best evidence in nutrition therapy for wound healing.

KKHS.jpegKimberly Knott is a registered dietitian who works as a diabetic educator in Swan Lake, Manitoba and at Ginew Wellness Center for a first nation’s community in Roseau River, Manitoba. She has worked in 11 different institutions in Southern Manitoba. Kim has always been interested in health issues, like chronic wound care, where nutrition has the potential to ease suffering and lower health care costs. She can be reached at kknott@southernhealth.ca



  

Chronic wound healing has been identified as a growing problem in my health region and across Canada. It’s a problem that contributes to health care costs and, more importantly to me, to the suffering of patients.  
 
I began investigating the latest research in nutrition therapy to address this problem in January 2014.  A nurse I work with, Roberta Moore, had asked me to help her understand the nutritional aspects of chronic wound healing and to help her with a difficult case.  I was able to share my findings with my team thanks to the support of my supervisor, Chantelle D’Andrematteo, RD, who recognized the importance of this area of nutrition therapy.
 
The Canadian Association of Wound Care estimates that:
  • the average cost of treating a chronic wound in Canada is $10,3761
  • diabetes-related foot ulcers cost our Canadian health care system $150 million annually1

 My research process
 PEN-Logo-small.jpg
1) I started with Practice-Based Evidence in Nutrition (PEN). I reviewed the “Wound Care” and “Wound Care – Pressure Ulcer” knowledge pathways.5
 
2) Then, I searched for position papers. These were great resources because they gave practical ideas on how to apply current knowledge.
 
3) Finally, I did a Google Scholar search for literature published since 2011, and conducted a regular Google search.  This retrieved one of my best Canadian resources: “Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury.”2
 
This resource, produced by the Rick Hanson Institute, was a two-year project done by a panel of experts, including Pamela Houghton, TP, PhD,  Chris Fraser, HBSc, RD and 12 others from various disciplines. It included a great chapter on nutrition that confirmed many of my previous findings.
 
A summary of my findings (illustrated in flow chart below)
 
The nutritional recommendations that are suggested have a “strength of evidence” letter attached to them. These letters are determined using the guidelines discussed in the National Pressure Ulcer Advisory Panel White Paper. 3 You can find the criteria for the “strength of evidence” ratings here (on page nine).
 
If a client is at nutritional risk:
  • Increase energy intake to 30-35kcal/kg, protein to 1-1.5g/kg (strength of evidence = A)2 and start a multivitamin/mineral supplement (strength of evidence = B).2
protein.jpg
  • If there is no wound improvement in 15-20 days, supplement with collagen hydrolysate3 (no strength of evidence rating) and/or arginine could be considered2  (strength of evidence = lower B).
  • Vitamin C supplementation above recommended levels does not have any clear evidence of efficacy.2
  • Omega-3 fatty acid supplementation is not recommended because this may inhibit collagen synthesis. 4
supplements.jpg
  • Vitamin E supplementation is not recommended because it may enhance the inflammatory response (strength of evidence =C).2
  • Zinc supplementation above recommended levels has no clear evidence of efficacy and may cause gastrointestinal distress and a secondary copper deficiency.2
  • Provide 1ml fluid/kcal consumed (strength of evidence = C).2
Chart-for-Nutritional-Intervention-for-Chronic-Wounds-small.jpg

A case study
 
The difficult case that the nurse had asked me to help with was a client that had been a paraplegic for 20 years and had developed a large chronic wound on his gluteus maximus. His wound had not healed for 12 months. He was using negative pressure wound therapy (a sealed wound dressing attached to a vacuum pump), however, nothing had been working.
 
His fluid intake and protein support were sufficient but he had run out of his multivitamin six months ago. He did mention that he had taken salmon collagen years ago and it had helped heal a previous wound.

fluid-(1).jpg
 
I helped him source salmon collagen, reminded him of the importance of good protein support and suggested he start taking a multivitamin again. Roberta Moore, RN also made some nursing treatment changes using a risk assessment tool called the Braden Scale.
 
In three weeks, his wound began to heal and, after six weeks, there was marked improvement. Working together with Roberta, and using the latest evidence in chronic wound nutrition therapy was essential in treating this complex health problem.  
 
Supply the fuel
 
Healing a wound is like doing renovations on your house after it has been damaged. Good nutrition supplies the fuel and building materials. Good nursing and medical care clears out debris, encourages the building of the foundation (granulation tissue), prevents further damage by looters (infection), and promotes good finishing carpentry (skin reconstruction).

homereno-(1).jpg
 
Sharing my findings
 
After conducting the literature search and summarizing my main findings, I developed a protocol and nutritional intervention flow chart (below) for wound healing. We use the Malnutrition Screening Tool to determine if an RD referral is indicated.
 
Three months later, I presented the protocol, “Nutritional Therapy in Chronic Wound Treatment,” to the Southern Health dietitians in Manitoba.  Many dietitians since then have said the protocol has been a valuable tool for them. Teaching other dietitians about this protocol provided a great opportunity to discuss the specific nutritional challenges we have faced in this area.
 
Going through this process from conducting research, to protocol development, to educating others was an exceptional experience. I would do it again in a heartbeat! It was great seeing nutrition play a key role in easing a client’s suffering and I enjoyed the synergy of working with another health care professional.
 
I am currently working on a pamphlet for our health region, which will be used by home care nurses, to provide practical information to clients with chronic wounds. This pamphlet discusses the rationale behind increased energy and protein intake, and provides some simple, high protein, milkshake and smoothie recipes.  I hope it will become a valuable tool for caregivers who provide day-to-day nutritional care.
 
Get inspired
 
It is my hope that my experience will inspire you to update the protocols in your organization. I continue to be called into difficult cases and, having done this research, I feel much more confident in the nutritional therapy I recommend.  Nutrition is often forgotten in chronic wound healing, but I think in the future it will become one of the first considerations.
 
References
  1. Canadian Association of Wound Care. (n.d.) Statistics. Retrieved from http://cawc.net/index.php/public/facts-stats-and-tools/statistics/
  2. Rick Hansen Foundation. (2013, Feburary). Canadian best practice guidlines for the prevention and managment of pressure ulcers in people with spinal cord injury. Retrieved from http://onf.org/system/attachments/168/original/Pressure_Ulcers_Best_Practice_Guideline_Final_web4.pdf
  3. Dorner, B., Posthauer, M., & Thomas, D. (2009, May). The role of nutrition in pressure ulcer prevention and treatment: National pressure ulcer advisory panel white waper. Retrieved from http://www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-Website-Version.pdf
  4. Boulom, V., & Barbul, A. Advances in wound care: Volume 2 omega-3 fatty acids modulate wound healing. Retrieved from http://online.liebertpub.com/doi/abs/10.1089/9781934854280.301
  5. Dietitians of Canada. (2010). Wound Care - Pressure Ulcers Evidence Summary. Retrieved from Practice-based Evidence in Nutrition [PEN]: http://www.pennutrition.com/KnowledgePathway.aspx?kpid=7871&trid=7859&trcatid=42
 

Editor’s note: It is great to see Kim’s research and experience in this area benefiting so many others and improving patient care. Kim is happy to share the pamphlet that she has developed when it is available. Please email her for further details if interested.

Malnutrition affects the healing of wounds, length of hospital stay and much more. Check out DC’s detailed paper, “An Inter-professional Approach to Malnutrition in Hospitalized Adults,” to find out how dietitians can lead the way in this area!
 
Is there anything missing from Kim’s findings that you have used to help chronic wounds heal? Is there additional research that you would suggest referring to?
 
Please share your experiences, comments or questions for Kim below.

  1. Hi Jenna, You are right about the current evidence not supporting vitamin C, vitamin A and zinc to be given as individual supplements. There is however good evidence that a multivitamin does speed healing, especially if the client was malnourished for any length of time. ( See reference #3)
  2. Hi Sandra, I would be very interested in discussing a wound care protocol with you via email. I will check my kknott@southernhealth.ca address today Wednesday, December 28, Thursday, December 29, and Monday, Jan 2, at 5:00pm my time. I have guessed that this will be approximately 10:00am your time the next day. (17 hours ahead?) Please let me know if any of these work for you and suggest an alternative time if they do not.
  3. Hi Kimberley

    I am an endocrine dietitian working in a high risk foot clinic with patient both coming in with diabetic ulcers/pressure injuries as well as large post op wounds from amputations. I am trying to develop a protocol for patients with wounds including arginine for chronic ones. I have never heard of collagen hydraslate but will certainly google it. I would really like an opportunity to get some advice from you regarding setting up a such a protocol here in Australia in our foot clinic. Is there any chance we could arrange a time to email each other?

    Kind regards
    Sandra Daugalis
  4. Thank you for sharing this important information! To clarify some of the information provided in the flow chart, is there evidence to support the need for micronutrient supplementation to help in wound healing? Is a multivitamin suggested, or are individual nutrients required as well (Vitamin A, Vitamin C, zinc)? I'm working off of information I received a few years ago that indicate that for Stage 3, 4 and unstageable wounds, that it's important to consider 50 mg Zinc x10 days, 10,000 IU Vitamin A x10 days, and 500 mg Vitamin C TID x14 days. Looking at some of the current research I'm finding limited evidence to support this supplementation; do you have any recommendations in regards to this? Thank you!
  5. If you are interested in more in depth information on the topic of wound care look into Dietitians of Canada Learning on Demand presentation titled
    "Nutrition Guidelines for Pressure Ulcer Prevention and Treatment" by Becky Dorner RDN, LD, FAND. It gives a wonderful overview of all the recent guidelines and many other valuable insights into nutrition and wound care.
  6. Hi Andrea, Thank you for pointing me toward Dr. Dover's very interesting meta analysis. What surprised me is that arginine deficiency after surgical stress was identified 30 years ago. He concludes his article with this statement

    "In conclusion, in this review we have demonstrated some clinical evidence that use of nutrition therapy containing arginine and omega-3 fatty acids used both pre- and postoperatively in high-risk elective surgical patients is associated with a substantial reduction in infection and shorter length of hospital stay. Efforts to implement the use of these diets in the perioperative setting are worthwhile. These efforts will result in considerable reduction in morbidity for our patients and substantial reductions in costs for the health care system."

    http://www.researchgate.net/profile/Rupinder_Dhaliwal/publication/49767644_Perioperative_use_of_arginine-supplemented_diets_a_systematic_review_of_the_evidence/links/5424169d0cf26120b7a71862.pdf
    This convinces me that I should try Impact AR the next time I have a difficult case.

    Interestingly enough, when I presented the information about arginine to the dietitians in my area, one of the dietitians, who did his internship in Cuba, said that L-arginine was routinely given to burn patients. We asked him if it was effective and he said the results were amazing.
  7. The blend of arginine, omega 3 and nucleotides in this immunonutrition formula, when combined together in the right dose (as studied in Impact AR) seems to promote highly reduced infection rates post op. I am referring to Dr. J. Drover's 2011 meta analysis in JACS on preop arginine where he cites Impact AR being used to reduce surgical site infections by upwards of 50% in UGI and LGI surgeries. When you look at mechanisms of action, really SSIs and anastomoses are "wounds" so it would follow in my mind that it may also help heal decubitus ulcers although there is no literature yet to support that specifically. I don't believe that minimal amounts of N-3 inhibit wound healing, otherwise I think we would see RDs starting to limit the 2 servings of fatty fish/week that is recommended to all who suffer wounds. The "anticoagulation" effect of n-3's in surgical patients has already been quashed by adequate research and the evidence (as you pointed out) for inhibition of wound healing is poor.
  8. Hi Andrea, I am sorry I don't have any anecdotal evidence of results from using Nestle's Health Science ONS Impact AR because when I investigated it I found it contained fish oil (Omega-3-fatty acids) and I felt even though there is not strong evidence against omega -3-fatty acids I did not want to risk it.

    I listed one reference that suggested omega-3 fatty acids increase healing time and here is another study done on humans that finds the same delayed healing.

    J. McDaniel, M. Belury, K Ahijevch, & W. Blakely (2008). Omega-3-fatty acids effect on wound healing. Wound Repair & Regeneration , 16 (3), 337-345.
  9. It is wonderful to see RDs take the initiative to perform such reviews based upon their expertise. I am wondering whether you have ever tried using immunonutrition for wound healing such as Nestle Health Science's ONS Impact AR, and if so, what your (anecdotal) results have been? It contains an immunonutritive blend of arginine, N-3, nucleotides and antioxidants.
  10. Hi Cindy, Thank you for helping clarify what the flowchart says about collagen. It does not have an evidence rating therefore there is no clear evidence of its efficacy. I agree with you that those who have used it with success should attribute the success to higher protein intake. In my subsequent cases of treating chronic wounds I have used all kinds of protein forms (beneprotein, milk powder, and larger meat portions) with good success. In the future I will consider taking collagen out of the flowchart.
  11. Thank you for sharing your journey and the valuable information. Your flow chart will be helpful for many. I have only one suggestion. There isn't good quality evidence about the use of collagen. The one study available did not have a suitable control, therefore, the only thing that can be concluded is that extra protein helped heal the pressure ulcers. For this reason, I would just change the collagen supplementation part to further protein supplementation. This will then open up the possibilities for patients to get extra protein without having to source out collagen specifically.
  12. Hi Amanda, If you do a search for Organika High Potency Salmon Collagen, you will find it's available from 4-5 different online companies and it is also available sometimes from Costco.
  13. Yay for collagen! Just out of curiosity where did you source out the salmon collagen? I personally buy the Great Lakes brand on amazon but its beef derived. TIA :)
  14. Thank you to Kimberly for this wonderful article. I no longer work in the clinical setting but this is a great example of how to take stock of a topic in any area of practice, and apply the latest findings. Much appreciated!

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