Case Study: Pressure Ulcers in a SCI Patient

Presentation by Lily Doher, Dietetic Intern of MGL

December 5, 2014

Learner Objectives• Learners should be able to…

• Gain a comprehensive understanding of how a patient’s social, health and medical history can influence their condition and recovery.

• Explain the pathophysiology of pressure ulcers.

• Recall conditions or factors that may increase a patient’s risk for developing a pressure ulcer(s) and how these conditions may complicate the treatment of pressure ulcers.

• Demonstrate the medical nutrition therapy and nutrition care process for a patient with pressure ulcers.

Introducing the Patient

• A.L.

• 34 year old male

• Paraplegic T8 down

• Admitted Sept 6, 2014

• Dx: complicated UTI

• Severe pressure ulcers

Role of the RD in SCI

• Active in acute phase, rehabilitation setting and community setting

• Evidence suggests MNT provided by RD results in…

• Improved nutrition-related outcomes

• Adequate nutrient intake

• Weight

• Bowel management

• Dysphagia

• Pressure ulcers

Medical Nutrition Therapy

Nutrition Assessment

• Client history

• Food- and nutrition-related history

• Anthropometrics

• Nutrition-focused physical findings

• Biochemical and medical tests, procedures

Medical History

• Anxiety, GERD, CKD

• Suicide attempt 09/2009– stab wound to RUQ

• Multiple ER visits for ETOH intoxication

• Pressure ulcers first appeared in 2012

• MGL 12/2013 for ulcers

• Per ER Triage: wounds neglected, down to the bone

• MGL 01/2014 for stage 4 pressure ulcers, osteomyelitis

• DKA 4 times, hyperglycemia 4 times

Medical History

• Type 1 diabetic for 26 years

• States BS well-controlled at home

• Checks BS at least 2x/day, usually 3 with meals

• Home medications

• Multivitamin

• Levemir– 40 units

• Long acting insulin

• Aspart Injection– 6 units

• Fast-acting mealtime insulin

• Preferably TID with meals

Social History

• July of 2011– lost house

• August 2011– bought new house in Lansing

• Needed repairs, which AL did himself

• Spent weeks working in moldy basement, no mask

• Fell ill Hospitalization Dx of Transverse Myelitis

What is Transverse Myelitis?

• Rare neurological disorder; inflammatory disease that causes injury to spinal cord

• Exact cause is unknown • “viral, bacterial, fungal and/or even parasitic […]

etiology.”

• Attacks of inflammation can damage/destroy myelin

• Creates nervous system scars that interrupt communication between spinal nerves and rest of body

What is Transverse Myelitis?

What is Transverse Myelitis?

• Symptoms advance in as little as hours to weeks

• 1/3= full recovery

• 1/3= fair recovery, some significant deficits

• Spastic gait

• Sensory dysfunction

• 1/3= no recovery

• Paraplegic or quadriplegic

Social History

• Earned GED

• LCC MSU

• Licensed builder and certified mechanic

• Unemployed since becoming paraplegic

• Disability Medicaid coverage

Social History

• Lives alone in apartment with his cat

• “Plain” and “boring” life

• No socialization outside of family

• Family support:

• Mother, brother and sister all live in same complex

• Very close with nephew

• Father passed away from renal disease

Social History

• Does not drink– Hx of ETOH abuse

• Smokes tobacco, chews tobacco @ hospital

• Sleeps 8-10 hours/night

• Does not exercise d/t paralysis

• Could do arm exercises but chooses not to

• No appetite

• Uses medical marijuana to increase PO intake

Appetite in SCI

• “A person with a [SCI] above the level of the abdomen cannot feel if their stomach is hungry or full, so they have to remember when to eat and how much to eat.”

• Visceral sensory information is transmitted to the brain through the afferent vagus nerve

• Ghrelin, a peptide produced in the stomach, travels to the hypothalamus to stimulate feeding

• A study done in rats found that blockade of the gastric vagal afferent abolished ghrelin-induced feeding

• This explains why a person with a spinal cord injury does not feel hunger sensations

Medical Marijuana and Appetite

• Cannabinoids: natural compounds found in marijuana, act on specific receptor sites within the brain and reflect the physiological role of their natural ligands

• Ex: Delta-9-tetrahyrdocannibinol (THC)

• Endocannabinoids: substances occurring naturally in the body that activate cannabinoid receptors

• Ex: N-arachidonoylethanolamine (anandamide)

• Cannabinoid receptors: cell membrane receptors that are activated by three major groups of ligands: endocannabinoids, plant cannabinoids and synthetic cannabinoids

• CB1 (located in central nervous system)

• CB2 (located in periphery)

Medical Marijuana and Appetite

• Endocannabinoids initiate appetite by stimulation of CB1 receptors in the hypothalamic areas involved in the control of food intake

• Endocannabinoids contribute to incentive processes and to hedonic evaluation of food

• “wanting” and “liking”

• Induce a psychological craving for

food and not just a physiological

Nutrition Knowledge

• States knowledge of nutrition is “stellar”

• Food intake history:

• Lots of protein/meats

• Hamburgers, eggs, chicken, peanut butter, whey

• Drinks mostly water, no pop or sugary beverages

• Wide variety of vegetables

• Asparagus, squash, eggplant, Brussels sprouts

• Stays away from sugar

• Small portions d/t not being able to feel full

Demographics

ALFood stamps

No grocery stores in walking distance

Party store access via

wheelchair

Homecare nurse

Homecare Nurse

• 5 days/week, 8 hrs/day through Home Care Alternatives• Provides wound care (pt does not f/u w wound clinic)

• Per social work: pt regularly declines in-home skilled care soon after he returns from the hospital repeatedly d/c from homecare for noncompliance • Does not want strangers in his home

• Pt recently d/c with Sparrow Hospice declined visits from hospice nurse discon’t for noncompliance admitted to MGL next day

Handicaps Related to Eating

• Does not cook for himself

• Able to take bus to grocery store if needed

• Usually brother or caregiver shops for him

• Brother/caregiver prepares food• 3 meals/day

• Snacks he gets himself

Anthropometrics

• Ht: 66”

• Current wt: 145#

• BMI: not to be used for pt’s with SCI

• IBW: 142#

• AIBW for paraplegia: see Metropolitan Life Tables

• UBW pre-paraplegia: 172#

• Wt Hx: 10/10/12 165#, 01/12/14 157#

Metropolitan Height and Weight Tables

Nutrition-Focused Physical Findings

• Gastrointestinal issues and bladder/bowel dysfunction

• Occur in 27%-62% of pt’s with a SCI

• Multiple UTI’s

• Unable to control bladder need for catheter increased risk of infection

• Colostomy

• Dental issues

• Cavities had to get 19 teeth pulled

• Full upper denture set

• States does not affect his eating

Nutrition-Focused Physical Findings

Stage IV Ulcer Sacrum

• 3 cm long

• 2 cm wide

• .4 cm deep

• Slough pink

• Granulation pink

Unstageable Ulcer Posterior Scrotum

• 2 cm long

• 1 cm wide

• .7 cm deep

• Moderate tan drainage

Pressure Ulcers

• AKA bedsores, pressure sores, decubitus ulcers

• Injuries to skin and underlying tissue resulting from prolonged pressure

• Often develop on skin that covers bony areas of the body

• Buttocks

• Hips

• Elbows

• Heels

• Shoulders

• Can quickly develop, often difficult to treat

Epidemiology

• Incidence:

• 2.3% to 23.9% in long-term care

• 0.4% to 38% in acute care

• 0% to 17% in home care

• Prevalence:

• 2.3% to 28% in long-term care

• 10% to 18% in acute care

• 0% to 29% in home care

• Higher level SCI lesions = risk

• Fuhrer MJ, et al: 33 of 100 pt’s with stage II or greater

Pathophysiology

• Pressure disrupts normal circulation to skin and deep structures

• Complex vascular system (large veins and capillaries) runs throughout the dermis to supply the skin

• Arteriole capillary pressure 32 mmHG = disrupted blood flow

• Venous capillary closing pressure 8-12 mmHG = impedes return of flow

• Prolonged pressure ischemia, necrosis, ulceration

Pathophysiology

Etiology

• Immobility

• Age

• Lack of sensory perception

• Weight loss

• Poor nutrition/hydration

• Excessive moisture or dryness

• Bowel incontinence

• Medical conditions affecting blood flow

• Smoking

• Limited alertness

• Muscle spasms

The Braden Scale

AL’s Risk Factors

• Braden Score 12/23

• Immobility

• Lack of sensory perception

• Bowel incontinence

• Smoker

• Poor nutrition (?)

Wound Staging

Stage I

Stage II

Stage III

Stage IV

Unstageable

Suspected Deep Tissue Injury

Medical Treatment

• Negative pressure wound therapy (NPWT)

• Vacuum pump, drainage tubing, foam or gauze wound dressing, and an adhesive film dressing that covers and seals the wound

• Wound V.A.C.

• Creates continuous or intermittent negative pressure inside the wound to remove fluid, exudates, and infectious materials

• Maggots

• To clean out the necrotic tissue

NPWT/Maggots Medical Treatment

Medical Treatment

• Surgical/sharp debridement: use to remove large amounts of thick eschar and infected tissue; or need for urgent debridement

• Mechanical debridement: used on wounds with moderate necrotic tissue (eschar)

• Pressurized irrigation device

• Low-frequency mist ultrasound

• Specialized dressings

Surgical/Mechanical Debridement

Medical Treatment

• Autolytic debridement: used on wounds with small to moderate amounts of eschar; enhances body’s natural process of using enzymes to breakdown dead tissue• Hydrocolloids• Hydrogels • Transparent film

• Enzymatic debridement: used on wounds with a significant amount of necrotic tissue; involves applying chemical enzymes and appropriate dressings

Autolytic/Enzymatic Debridement

Medical Treatments

• Skin flaps• Portion of skin and tissue moved to fill defect • Results in a new defect at donor site • Often can be closed primarily, sometimes requires skin grafting

• Axial• Random • Rhomboid • Rotation• V-Y Advancement

• Muscle flaps• Moving a local muscle to cover an exposed bone or

fracture

AL’s Surgical History

AL’s Infection

• On 9/10 found infection in wound

• Gram negative bacilli three colony types, proteus species +/T/ group D enterococcus

• Enterococci are a part of the normal intestinal flora of humans and animals

• One study found in its subjects group D enterococcus was one of the most common aerobic isolates from pressure ulcers

Hospital Medications Medication Classification Use Mechanism Possible FDI

Rocephin

CephalosporinAntibiotic

Treat bacterialinfections

Inhibits mucopeptide synthesis in the bacterial cell wall

Anorexia, dry mouth, metallic taste, N/V, diarrhea, constipation

Diflucan

Anti-fungal medicine

Treat infections caused by fungus

Inhibits fungal cytochrome dependent enzyme

N/V, abdominal pain, taste changes

Lovenox

Anticoagulant Treat or prevent a DVT or PE

Binds to and accelerates theactivity of antithrombin III

Nausea,diarrhea

Hospital MedicationsMedication Classification Use Mechanism Possible FDI

Nicoderm

Smoking cessation adjunct

Reduce craving and withdrawal symptoms associated with smoking

Binds to nicotine receptors in body

Nausea

Protonix

Proton pump inhibitor

Treatment of conditions such as ulcers or GERD that are caused by stomach acid

Suppresses final step in gastric acid production by binding to the H+, K+ ATPase enzyme systemat the secretory surface of gastric parietal cell

Long-term use may may it harder for your body to absorb vitamin B12, weight changes, N/V, diarrhea, gas, stomach pain

Hospital MedicationsDrug Class Mechanism Use Possible FDI

Cipro Quinolone antibiotic

Inhibits enzymes required for DNA processes

Treat infections of the skin, bone, sinus, lung, abdomen and bladder

Do not take along with dairy products or multivitamins

NovoLog Insulin aspart Bind to insulin receptors and increase cellular uptake of glucose and inhibiting the output of glucose from the liver

Fast-acting form of insulinthat acts to lower blood glucose

N/A

Levemir Insulin detemir See above Basal insulin that acts to lower blood glucose

N/A

Biochemical

“Cross-sectional studies associate… low serum albumin, low serum cholesterol and low hemoglobin levels with pressure ulcers.”

Biochemical

9/7 9/8 9/9 9/10

Hemoglobin(14-17 g/dL)

10.7 10.8 10.2 9.3

Albumin (3.4-5.0)

1.9 2.0

Biochemical

9/6 9/7 9/8 9/9 9/10

White Blood Cells

(4.5-10.5)

12.7 13 12.7 12.5 10.3

C-ReactiveProtein

(0-0.9 mg/dL)

4.0

Glucose Bedside

49

158

128

83

238

0

50

100

150

200

250

0:00 4:48 9:36 14:24 19:12 0:00

9/7 AccuChecks

*

*

*

Glucose Bedside

45

84

61

101

218

0

50

100

150

200

250

0:00 4:48 9:36 14:24 19:12 0:00

9/8 AccuChecks

*

*

*

Glucose Bedside

92

146 147

263

0

50

100

150

200

250

300

0:00 4:48 9:36 14:24 19:12 0:00

9/9 AccuChecks

*

*

*

Glucose Bedside

222

66

142

405

0

50

100

150

200

250

300

350

400

450

0:00 4:48 9:36 14:24 19:12 0:00 4:48

9/10 AccuChecks

*

*

Glucose Bedside

175

62

21

49

194

233

0

50

100

150

200

250

0:00 4:48 9:36 14:24 19:12 0:00

9/11 AccuChecks

*

*

*

Diabetes and Wound Healing

Hyperglycemia

“self-perpetuating loop”

Infection

• “The healing process in diabetes is also jeopardized by the patient’s susceptibility to infection due to deficiencies on the innate immunity.” Berlanga-Acosta et al.

• Hyperglycemia reduces the function of immune cells and increases inflammation • Dysregulation of the inflammatory response can lead to

extensive tissue damage

• Excess glucose reduces the functional longevity of neutrophils

• Once a wound becomes infected it has a lower probability of healing

Now that we have gathered all of the factors affecting AL’s disease process, we are able to

make an appropriate diagnosis.

Nutrition Diagnoses

• Common nutrition diagnoses

• Inadequate oral intake (NI-2.1)

• Inadequate fluid intake (NI-3.1)

• Increased nutrient needs (NI-5.1)

• Malnutrition (NI-5.2)

• Inadequate protein intake (NI-5.7.1)

• Inadequate vitamin intake (specify) (NI-5.9.1)

• Inadequate mineral intake (specify) (NI-5.10.1)

Nutrition Diagnoses

Nutrition Intervention

• Reduced metabolic activity d/t denervated muscles

• BMR reported to be 14-27% lower for SCI pt than able-bodied individuals

• Increased fat mass and loss of fat-free mass

• Sympathetic blunting, cardiopulmonary dysfunction, reduced work capacity, and diminished anabolic hormones

• “Without diet adjustment to new metabolic requirements after SCI, energy intake quickly exceeds energy requirements, resulting in weight gain.” Crane DA et al.

• Clinical observations suggest SCI pt become obese within first 12 months after injury

Nutrition Intervention

• Energy needs in paraplegia without pressure ulcer present

• 27.9 kcal/kg

• Protein needs in paraplegia without pressure ulcer present

• 0.8-1 g/kg

• Energy needs in paraplegia with pressure ulcer present

• 30-35 kcal/kg

• Protein needs in paraplegia with pressure ulcer present

• 1.2-1.5 g/kg for stage II

• 1.5-2.0 g/kg for stage III and IV

Nutrition Intervention

• Normal fluid requirements: 30 ml to 40 ml/kg

• No less than 1 ml/kcal

• May need additional 10 ml to 15 ml/kg

• Evaporation of fluids from severe pressure ulcer

• Draining or open wounds

• Fever

• Use of air fluidized bed set at high temperature

Nutrition Intervention• Zinc

• Decrease in collagen and protein synthesis and impaired immune competence

• Recommendation: 50 mg elemental zinc BID for 2-3 weeks maximum

• Vitamin A

• Impaired wound healing and altered immune function

• Recommendation: 10,000-50,000 IU/day

• Vitamin C

• Delayed wound healing

• Recommendations:

• 100-200 mg/day for stage I and II pressure ulcers

• 1,000-2,000 mg/day for stage III and IV pressure ulcers

Nutrition Intervention

• Glutamine

• Conditionally essential amino acid

• Key role in immune system, deficiency can slow healing

• Arginine

• Semi-essential amino acid

• Promotion of nitrogen balance, cell proliferation, T lymphocyte fxn, collagen accumulation

• HMB

• Metabolite of leucine

• Inhibits muscle proteolysis, modulates protein turnover

Nutrition Intervention

• Williams JZ, Abumrad N, Barbul A. Ann Surg Sept 2002.

• Double-blind, randomized trial

• 35 healthy, nonsmoking humans 70 yrs or older• 18 received HMB, glutamine and arginine suppl.

• 17 received isonitrogenous, isocaloric nonessential AA suppl.

• “Collagen synthesis is significantly enhanced in healthy elderly volunteers by the oral administration of a mixture of arginine, HMB and glutamine.”

Nutrition Intervention

• Wong A, Chew A, Wang CM, et al. J Wound Care May 2014

• Placebo-controlled trial

• 23 inpatients with stage II, III or IV pressure ulcers in an acute care hospital

A. HMB, arginine and glutamine mixture BID

B. Standard nutrition care + oral nutritional supplements

• “The use of specialised amino acid does not appear to reduce wound size and PUSH scores but may improve tissue viability after 2 weeks. Further confirmation on a larger scale is required to determine the benefits of supplementing additional HMB, arginine and glutamine in patients with pressure ulcers.”

AL’s Nutrition Intervention

• 1600-2000 kcal/day (25-30 kcal/kg)

• 79-99 g PRO (1.2-1.5 g/kg)

• 1980 ml fluid (30 ml/kg)

• Regular diet

• Fruit punch Juven BID

• Strawberry Glucerna TID

What Would I Have Done Differently?

• 2200 ADA diet (33.4 kcal/kg)• Increased kcal intake for wound healing• ADA diet for better glucose control

• 99-132 g PRO (1.5-2.0 g/kg)• Stage IV pressure ulcers

• Special K protein bars, Glucerna only BID

• 50 mg elemental zinc BID

• 10,000-50,000 IU vitamin A

• 1,000-2,000 mg vitamin C

Monitoring and Evaluation

• Weight

• Anthropometrics

• Nutrient intake

• Wound stage/healing

• Hydration status

Monitoring and Evaluation

• Weight was stable throughout hospital visit

• Per meal intake record AL was eating 80-100% of meals

• See previous slides for laboratory tests

• Post-op:• Unstageable pressure ulcer debrided to stage III

• 9/10 started getting bedside I and D’s • For wound healing and to help clear the infection

Prognosis

• After 6 months of treatment

• > 70% of stage II

• 50% of stage III

• 30% of stage IV

• Often develop in pt’s receiving sub-optimal care

• Long-term outcome is poor if care cannot be improved (even if short-term wound healing was accomplished)

• Agency for Health Care Research and Quality 2006

• Pressure ulcers as primary diagnosis: 1 in 25 ended in death

• Pressure ulcers as 2nd diagnosis: 1 in 8 ended in death

Prevention• Repositioning (q 2 hrs)

• Specialty mattresses

• Foam, water, air to help with positioning

• Head of bed raised no more than 30° to prevent shearing

• Adequate nutrition to maintain skin integrity

• With care to pt’s activity status to prevent obesity

• Smoking cessation

Health Care Cost

• Estimated cost of treating pressure ulcers in 2008

• $9.2 to $15.6 billion

• Factor in 7% per year for health care inflation to get today’s cost

• Reported cost for treating a pressure ulcer in an acute-care setting (Centers for Medicaid/Medicare Services)

• $43,180 per hospital stay

• Cost Factors

• Increased length of stay d/t pressure ulcer complications: pain, infection, decreased functional ability

Cost Effectiveness

• Likely that cost of prevention less than treatment

• Reduced hospital visits

• Less recurrence of pressure ulcers

• i.e. ensuring adequate protein and micronutrient intake to promote healthy skin integrity and reduce risk of developing a pressure ulcer

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Berlanga-Acosta J, Schultz GS, Lopez-Mola E, et al. Glucose toxic effects on granulation tissue productive cells: the diabetics’ impaired healing. BioMed Research International. 2013;2013:15 p.

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