Features of nutritional status and the possibility of clinical nutrition in the prevention and treatment of pressure ulcers in patients in intensive care units

Pressure sores are a common affliction for patients in intensive care units, neurology, and rehabilitation after critical conditions, including trauma, acute cerebrovascular accidents and abdominal surgery. Despite the fact that a sufficient number of wound dressings have been created around the world to prevent and promote healing of wounds resulting from pressure on soft tissues, the features of nutritional status and clinical nutrition are rarely discussed. Chronic wounds (pressure sores and trophic ulcers) significantly reduce the quality of life of patients and place a heavy burden on the health care system. In the pathogenesis of the development of pressure sores, both external factors (chronic compression of the tissue covering the bone protrusion, friction or displacement of the body, exposure to moisture, immobility) and internal factors are involved – arterial hypertension, diabetes mellitus, age, malnutrition, etc. Malnutrition is a common factor the risk of developing chronically non-healing wounds in different groups of patients. Individuals with chronic wounds, including pressure sores, have been shown to perform worse on the Nutrition Screening Initiative and Norton than comparable patients without pressure sores, and populations at risk of developing chronic wounds are also at high risk of malnutrition. A high-protein, energy-rich, ready-to-use enteral tube feeding nutritional product has been specially developed for these cases. It is a complete enteral nutritional supplement with an innovative nutrient composition for patients with chronic wounds, including pressure sores, or at increased risk of developing them. It is fortified with many nutrients that play an important role in wound healing (arginine, vitamins A, C and E, other antioxidants, and zinc). The enteral tube feeding nutritional product also contains micronutrients that are often lacking in many patients with an increased risk of pressure sores and long-term non-healing wounds, for example, patients in hospital and in particular in intensive care units (including those with coronavirus infection), or the elderly. 

1. Al Aboud A. M., Manna B. Wound Pressure Injury Management. [Updated 2020 Jun 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532897/.

2. Cowan L., Garvan C., Rugs D., Barks L., Chavez M., Orozco T. Pressure Injury Education in the Department of Veterans Affairs: Results of a National Wound Provider Cross-sectional Survey // J Wound Ostomy Continence Nurs. 2018; 45 (5): 419-424. [PubMed].

3. Tappen R. M., Newman D., Huckfeldt P., Yang Z., Engstrom G., Wolf D. G., Shutes J., Rojido C., Ouslander J. G. Evaluation of Nursing Facility Resident Safety During Implementation of the INTERACT Quality Improvement Program // J Am Med Dir Assoc. 2018; 19 (10): 907-913. [PubMed].

4. Catania Q. N., Morgan M., Martin R. Activity-Based Restorative Therapy and Skin Tears in Patients with Spinal Cord Injury // Adv Skin Wound Care. 2018; 31 (8): 371-373. [PubMed].

5. Dincer M., Doger C., Tas S. S., Karakaya D. An analysis of patients in palliative care with pressure injuries // Niger J Clin Pract. 2018; 21 (4): 484-491. [PubMed].

6. Delmore B., Ayello E. A., Smart H., Sibbald R. G. Assessing Pressure Injury Knowledge Using the Pieper-Zulkowski Pressure Ulcer Knowledge Test // Adv Skin Wound Care. 2018; 31 (9): 406-412. [PubMed].

7. Li D., Mathews C., Zhang F. The characteristics of pressure injury photographs from the electronic health record in clinical settings // J Clin Nurs. 2018; 27 (3-4): 819-828. [PubMed].

8. Bocharnikova N. V., Yekimova N. A., Pasyuga V. V., Tarasov D. G., Shashin S. A. Mera profilaktiki prolezhney u kardiokhirurgicheskikh patsiyentov – sestrinskiy protokol ukhoda. [A measure for the prevention of pressure ulcers in cardiac surgery patients is a nursing protocol.] Doklad na XX Vserossiyskom s"yezde serdechno-sosudistykh khirurgov, 25.11.2014.

9. Mal'tseva L.A., Mosentsev N.F., Mishchenko Ye.A., Lisnichaya V.N., Sakovich Ye.F. Profilaktika i lecheniye prolezhney v otdeleniyakh intensivnoy terapii (obzor literatury). [Prevention and treatment of pressure ulcers in intensive care units (literature review).] Meditsina neotlozhnykh sostoyaniy, 2017, № 3, pp. 100-104.

10. Turkina N.V. Prolezhni. Ukhod za patsiyentom. [Pressure sores. Patient care.] Meditsinskaya sestra, 2018, № 1, pp. 49-56

11. Dibirov M.D., Prolezhni: profilaktika i lecheniye. [Pressure sores: prevention and treatment.] Ambulatornaya khirurgiya. Statsionarzameshchayushchiye tekhnologii, 2016, № 1-2 (61-62), pp. 57-63.

12. Cereda E., Gini A., Pedrolli C., Vanotti A. Disease-Specific, Versus Standard, Nutritional Support for the Treatment of Pressure Ulcers in Institutionalized Older Adults: A Randomized Controlled Trial., Copyright the Authors Journal compilation r 2009, The American Geriatrics Society: JAGS 57: August 2009. VOL. 57, № 8. С. 1395-1402.

13. Allman R. M. Pressure ulcer prevalence, incidence, risk factors, and impact // Clin Geriatr Med. 1997; 13 (3): 421-36. PMID: 9227937.

14. Bennett G., Dealey C., Posnett J. The cost of pressure ulcers in the UK // Age Ageing. 2004; 33 (3): 230-235. DOI: 10.1093/ageing/afh086. PMID: 15082426.

15. Yarkony G. M. Pressure ulcers: a review // Arch Phys Med Rehahil. 1994; 75: 908-917.

16. Bhattacharya S., Mishra R. K. Pressure ulcers: Current understanding and newer modalities of treatment // Indian J Plast Surg. 2015; 48 (1): 4-16.

17. Guralnik J. M., Harris T. B., White L. R., Cornoni-Huntley J. C. Occurrence and Predictors of Pressure Sores in the National Health and Nutrition Examination Survey Follow-up // Journal of the American Geriatrics Society. 1988; 36: 807-812.

18. Berlowitz D. R., Wilking S. V. The short-term outcome of pressure sores // J Am Geriatr Soc. 1990; 38 (7): 748-752. DOI: 10.1111/j.1532-5415.1990.tb01464.x. PMID: 2370394.

19. Saghaleini S. H., Dehghan K., Shadvar K., Sanaie S., Mahmoodpoor A., Ostadi Z. Pressure Ulcer and Nutrition // Indian J Crit Care Med. 2018; 22 (4): 283-289.

20. Horn S. D., Bender S. A., Ferguson M. L., Smout R. J., Bergstrom N., Taler G., et al. The national pressure ulcer long-term care study: Pressure ulcer development in long-term care residents // J Am Geriatr Soc. 2004; 52: 359-367.

21. Guenter P., Malyszek R., Bliss D. Z., Steffe T., O’Hara D., LaVan F., et al. Survey of nutritional status in newly hospitalized patients with stage III or stage IV pressure ulcers // Adv Skin Wound Care. 2000; 13: 164-168.

22. Mathus-vliegen E. M. H. Nutritional status, nutrition and pressure ulcers // Nutr Clin Pract. 2001; 16: 286-291.

23. Stratton R. J., Ek A. C., Engfer M., Moore Z., Rigby P., Wolfe R., et al. Enteral nutritional support in prevention and treatment of pressure ulcers: A systematic review and meta-analysis // Ageing Res Rev. 2005; 4: 422-450.

24. Fry D. E., Pine M., Jones B. L., Meimban R. J. Patient characteristics and the occurrence of never events // Arch Surg. 2010; 145: 148-151.

25. Iizaka S., Okuwa M., Sugama J., Sanada H. The impact of malnutrition and nutrition-related factors on the development and severity of pressure ulcers in older patients receiving home care // Clin Nutr. 2010; 29: 47-53.

26. Blanc G., Meier M. J., Stocco J. G., Roehrs H., Crozeta K., Barbosa D. A., et al. Effectiveness of enteral nutritional therapy in the healing process of pressure ulcers: A systematic review // Rev Esc Enferm USP. 2015; 49: 152-161.

27. Cox J., Rasmussen L. Enteral nutrition in the prevention and treatment of pressure ulcers in adult critical care patients // Crit Care Nurse. 2014; 34: 15-27.

28. Montalcini T., Moraca M., Ferro Y., Romeo S., Serra S., Raso M. G., et al. Nutritional parameters predicting pressure ulcers and shortterm mortality in patients with minimal conscious state as a result of traumatic and non-traumatic acquired brain injury // J Transl Med. 2015; 13: 305.

29. Thomas D. R. Unintended weight loss in older adults // Aging Health. 2008; 4: 191-200.

30. Ryan C., Bryant E., Eleazer P., Rhodes A., Guest K. Unintentional weight loss in long-term care: Predictor of mortality in the elderly // South Med J. 1995; 88: 721-724.

31. Sullivan D. H., Johnson L. E., Bopp M. M., Roberson P. K. Prognostic significance of monthly weight fluctuations among older nursing home residents // J Gerontol A Biol Sci Med Sci. 2004; 59: M633-639.

32. Crowe T. Nutrition therapy in the prevention and treatment of pressure ulcers // Wound Practice Res. 2009; 17: 90-99.

33. Hartgrink H. H., Wille J., König P., Hermans J., Breslau P. J. Pressure sores and tube feeding in patients with a fracture of the hip: A randomized clinical trial // Clin Nutr. 1998; 17: 287-292.

34. Breslow R. A., Bergstrom N. Nutritional prediction of pressure ulcers // J Am Diet Assoc. 1994; 94: 1301-1304.

35. Chernoff R. Protein and older adults // J Am Coll Nutr. 2004; 23: 627S-630S.

36. Dorner B., Posthauer M. E., Thomas D. National Pressure Ulcer Advisory Panel. The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel white paper // Adv Skin Wound Care. 2009; 22: 212-221.

37. Langer G., Schloemer G., Knerr A., Kuss O., Behrens J. Nutritional interventions for preventing and treating pressure ulcers // Cochrane Database Syst Rev. 2003; 4: CD003216.

38. Tanuseputero S. A., Lin M.-T., Yeh S.-L., Yeh C.-L. Intravenous Arginine Administration Downregulates NLRP3 Inflammasome Activity and Attenuates Acute Kidney Injury in Mice with Polymicrobial Sepsis // Mediators Inflamm. 2020; 2020: 3201635. Published online 2020 May 11.

39. Bertolini G., Luciani D., Biolo G. Immunonutrition in septic patients: a philosophical view of the current situation // Clinical Nutrition. 2007; 26 (1): 25-29.

40. Rosenthal M. D., Carrott P. W., Patel J., Kiraly L., Martindale R. G. Parenteral or enteral arginine supplementation safety and efficacy // The Journal of Nutrition. 2016; 146 (12): 2594S-2600S. DOI: 10.3945/jn.115.228544.

41. Luiking Y. C., Poeze M., Deutz N. E. Arginine infusion in patients with septic shock increases nitric oxide production without haemodynamic instability // Clinical Science. 2015; 128 (1): 57-67.

42. Popovic P. J., Zeh H. J., Ochoa J. B. Arginine and immunity // The Journal of Nutrition. 2007; 137 (6), 6 Supplement 2: 1681S-1686S.

43. Kim Y. M., Talanian R. V., Li J., Billiar T. R. Nitric oxide prevents IL-1beta and IFN-gamma-inducing factor (IL-18) release from macrophages by inhibiting caspase-1 (IL-1beta-converting enzyme) // Journal of Immunology. 1998; 161 (8): 4122-4128.

44. Hernandez-Cuellar E., Tsuchiya K., Hara H., et al. Cutting edge: nitric oxide inhibits the NLRP3 inflammasome // Journal of Immunology. 2012; 189 (11): 5113-5117.

45. Mao K., Chen S., Chen M., et al. Nitric oxide suppresses NLRP3 inflammasome activation and protects against LPS-induced septic shock // Cell Research. 2013; 23 (2): 201-212.

46. Kandhare A. D., Patil M. V. K., Bodhankar S. L. L-arginine attenuates the ethylene glycol induced urolithiasis in ininephrectomized hypertensive rats: role of KIM-1, NGAL, and NOs // Renal Failure. 2015; 37 (4): 709-721.

47. Wischmeyer P. Nutrition therapy in sepsis // Crit Care Clin. 2018; 34 (1): 107-125. Published online 2017 Oct 13.

48. Silverio R., Gonçalves D. С., Andrade M. F., Seelaender M. Advances in Nutrition. Coronavirus Disease 2019 (COVID-19) and Nutritional Status: The Missing Link, Рublished: 25 September 2020.

49. Hill M. A., Sowers J. R., Mantzoros C. S. Commentary: COVID-19 and obesity pandemics converge into a syndemic requiring urgent and multidisciplinary action // Metabolism. 2021; 114: 154408.

50. Charlson M. E., Pompei P., Ales K. L., McKenzie C. R. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation // J Chron Dis. 1987; 40 (5): 373-383.

51. Munoz N. et al. The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations // Advances in Skin & Wound Care. 2020. Т. 33. №. 3. С. 123-136.