Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 25

CLINICAL PRACTICE GUIDELINE

T O TA L PA R ENT E RA L NUT RIT ION (T PN)

Parenteral nutrition support is indicated in
the presence of mechanical obstruction of the
GI tract, prolonged ileus, severe GI hemorrhage,
severe diarrhea, intractable vomiting, and highoutput GI fistula. Concentrated TPN solutions
(> 900 mOsm) are only tolerated through central
venous catheters and may cause thrombophlebitis
of peripheral veins. Patient-specific formulas can
be designed to deliver individualized nutrient
requirements. Complications of TPN include
mineral and electrolyte imbalances, acid-base
disorders, and catheter-related infections.
A N T H R O P O ME T RIC ME A S URE ME NT S

Commonly assessed anthropometric
measurements include body weight, BMI (weight/
height2), and triceps skinfold thickness (TSF).
Published anthropometric standards are based on
a non-SCI population and do not consider the
body composition changes (water shifts, muscle
atrophy from disuse, increased percentage of
body fat) that normally occur in individuals with
SCI. As ideal body weight standards have not yet
been established for individuals with SCI, the
Academy of Nutrition and Dietetics Spinal Cord
Injury Evidence-Based Nutrition Practice
Guideline suggests utilizing the Metropolitan Life
Insurance tables to estimate target body weight
for individuals with spinal cord injury with
estimated adjustments. Reported methods of
adjustment for tetraplegia include a reduction of
10-15% or a decrease of 15-20 pounds from the
table weight, while for persons with paraplegia,
a reduction of 5-10% or 10-15 pounds lower
than table weight has been recommended.
Decreased body weight (< 80% of ideal
weight) and low BMI (17.6 ± 4.6) have been
correlated with severe malnutrition and pressure
ulcer development (Bonnefoy et al., 1995; Ek et
al., 1991; Strauss and Margolis, 1996). It is
thought that the weight loss reduces fat and
muscle tissue, resulting in elevated pressures over
bony prominences and increased damage to
microcirculation, thus contributing to pressure
ulcer development (Schubert et al., 1994).
Nevertheless, BMI should be used with caution to
measure body composition in persons with SCI
due to concerns with accuracy (Jones et al.,
2003). If available, bioelectric impedance analysis
(BIA) or dual-energy X-ray absorptiometry
(DEXA) should be used to assess body
composition for persons with SCI who are
medically stable. Evidence suggests that BIA and
DEXA correlate with measures of total body water
(TBW) when labeled water is used to provide a
reference value for TBW.

TSF measurements have been found to be
significantly lower in individuals with pressure
ulcers than in those who do not have them
(Bonnefoy et al., 1995; Ek et al., 1991). Depleted
TSF defined as less than 3.0 mm for females and
,
less than 2.5 mm for males, has been significantly
associated with pressure ulcer development and
longer hospital lengths of stay (Allman et al.,
1995). However, TSF measurements should also
be used with caution in persons with SCI due to
concerns about accuracy, as any changes found
may be due to SCI rather than malnutrition as
Maggioni et al. (2003) demonstrated in
comparing skinfold measurements and dual X-ray
absorptiometry (DXA) between individuals with
and without SCI finding that the skinfold method
did not differ between the two groups. However,
fat mass was significantly greater in the SCI
group compared to controls when DXA was used.
BI OCHEMI CAL PARAMETERS

Several biochemical parameters have been
associated with the development or presence of
pressure ulcers. Normal reference ranges may
vary according to the laboratory consulted.
Prealbumin
Serum prealbumin levels are usually lower
(14 ± 4 mg/dL) in people with pressure ulcers as
compared to those without ulcers (Bonnefoy et
al., 1995). Prealbumin is a sensitive indicator for
monitoring nutritional adequacy due to its short
half-life of 2-3 days (Tuten et al., 1985). However,
there are some limitations of interpreting
prealbumin levels. Prealbumin is synthesized in
the liver and therefore synthesis is depressed in
the presence of hepatic disease. Rather than
monitoring prealbumin level for a specific range,
monitoring any trend in serial prealbumin levels
may be more useful.
Albumin and Total Protein
Historically, serum albumin levels have been
used as an indicator of nutrition status. Albumin
is synthesized in the liver, has a long half-life
(12-21 days), a large body pool, and may be
influenced by many non-nutrition related factors
(i.e., Inflammation, hepatic disease, fluid status).
A decrease in serum albumin levels cannot always
be correlated with visceral protein losses. Serum
albumin levels less than 3.5 mg/dL have been
significantly associated with an increased
incidence of pressure ulcers (Blaylock, 1995;
Ek et al., 1991; Lehman, 1995; Rochon et al.,
1993; Salzberg et al., 1996). Individuals who have
serum albumin levels of 3.5 g/dL or higher have
lower incidences of pressure ulcers than do
individuals with albumin levels lower than 3.5
g/dL (Bergstrom and Braden, 1992; Tourtual et

Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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