Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 27

CLINICAL PRACTICE GUIDELINE

Recommendations for increased protein
requirements in persons with pressure ulcers
range from 1.25 to 2 grams protein/Kg of body
weight per day with the higher requirements
suggested for those with ulcers of greater
severity (Bergstrom et al., 1994; Breslow et al.,
1993; Chin and Kearns, 1997).
Protein recommendations need to be
individualized and take into consideration if
there is concurrent hepatic or renal dysfunction
for which excess protein consumption can
be harmful.
A M I N O A C I DS

One observational study comparing healing
rates of pressure ulcers in persons with SCI who
were administered 9 grams of a commercial
powered arginine supplement per day with
historical controls reported a significantly shorter
mean healing time in the intervention group
(Brewer 2010).
M I C R O N U T R IE NT S

Deficiencies of micronutrients, especially
of zinc, vitamin C, and vitamin A, are associated
with poor wound healing. However, strong
evidence does not exist to demonstrate that
biochemical or dietary deficiencies of micronutrients are major risk factors for pressure ulcer
development. Moreover, supplementation of
micronutrients in individuals who do not have
deficiencies has not been shown to enhance
healing of pressure ulcers.
Zinc
Zinc is known to be involved in the structural
integrity of proteins, particularly collagen. Cruse
et al. (2000) found in a small study that serum
zinc levels are lower in those with SCI and
pressure ulcers as compared to those with SCI
without ulcers (52 mcg/dl as compared to 82
mcg/dl). Others, however, have found serum zinc
levels to be similar in people who develop and do
not develop pressure ulcers (Bergstrom and
Braden, 1992). Evidence also does not support
the idea that oral zinc sulfate supplements (220
mg daily) will affect the healing of pressure ulcers
within 2 to 3 months (Brewer et al., 1967). Longterm consumption of high amounts of zinc may
have adverse physiological effects, such as
impaired copper metabolism, which may induce a
state of copper deficiency and anemia (Eleazer et
al., 1995). However, use for a limited period of
time may be considered to correct a deficiency.

Vitamin C
Vitamin C plays a well-known role in the
hydroxylation of proline and lysine during
collagen formation. However, dietary intake of
vitamin C does not predict pressure ulcer
development (Bergstrom and Braden, 1992). In
addition, supplementation of vitamin C at a dose
of 500mg per day has not been shown to
accelerate healing of pressure ulcers in individuals
who are deficient in vitamin C (ter Riet et al.,
1995). Because a subclinical deficiency state is
difficult to diagnose, the minimum intake of the
RDA of 60 mg of vitamin C has been suggested.
Vitamin A
In one study of 110 SCI individuals, those
without a pressure ulcer over a 12-month period
were found to have higher vitamin A levels
(Moussavi et al., 2003). Vitamin A deficiency can
result in delayed wound healing. However, no
differences have been reported in the vitamin A
intake of individuals who do or do not develop
pressure ulcers (Bergstrom and Braden, 1992).
Iron, Vitamin B12 and Folate
Anemia assessed by hemoglobin and
hematocrit levels reduces oxygen supply to
tissues, thus impairing healing of pressure ulcers.
If low hemoglobin concentration is a result of
iron, Vitamin B12 or folate deficiency anemia,
it may be a factor in tissue hypoxia and impaired
wound healing. Supplementation should be
provided as indicated to correct iron, Vitamin
B12, or folate deficiency anemias if found.
F L UI DS

Inadequate fluid intake is a risk factor in the
development of pressure ulcers (Berglund and
Nordstrom, 1995; Ek et al., 1991). The Academy
of Nutrition and Dietetics evidence-based
guideline for the non-SCI population, specifically
30 mL to 40 mL per kilogram body weight or a
minimum of 1 mL per kilocalorie per day. For
those with pressure ulcers, additional fluid loss
may come from wound drainage and evaporative
losses caused by fever. A 10 mL to 15 mL per
kilogram additional amount of fluid may be
required with the use of air fluidized beds set at
a high temperature (more than 31º to 34ºC or
more than 88º to 93ºF) due to resultant increased
evaporative water losses (similar to fever)
(Breslow, 1994). Additional consideration should
be given to fluid intake in individuals with
conditions in which fluid needs to be restricted,
such as in renal and cardiac disease.

Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

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