Evaluation of Nutrition in the Healing of Pressure Ulcers: Are the EPUAP Nutritional Guidelines Sufficient To Heal Wounds?
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Abstract: Malnutrition is a significant factor in the development of pressure ulcers and many nutritional guidelines for preventing pressure ulcers have been published. However, few clinical investigations have examined the energy required to heal pressure ulcers. The aim of the present study was to investigate the relationship between nutritional intake and improvement of pressure ulcers. Total calories, which were supplied by mouth through a feeding tube and via venous alimentation were examined for 40 hospitalized bedridden inpatients who had pressure ulcers. Of these patients, 21 whose wounds improved or healed and 19 whose wounds became worse or did not improve were eligible for this retrospective study. Pressure ulcers in patients who received more than 30 kcal/kg per day improved or healed, while those of patients who received less than 20 kcal/kg per day worsened or failed to improve. Furthermore, intake of 30 kcal/kg per day enabled serum albumin levels to improve. Energy intake of 30 kcal/kg per day is comparable to the predicted total energy expenditure and is thought to be essential for improving pressure ulcers in bedridden patients.
Address correspondence to:
Masaki Fujioka, MD, PhD
Department of Plastic and Reconstructive Surgery
National Hospital Organization, Nagasaki Medical Center
1001-1 Kubura 2
Nagasaki, Japan 856-8562
Phone: 0957-52-3121
Email: mfujioka@nmc.hosp.go.jp
Malnutrition is a significant factor in the development of pressure ulcers and many studies have shown that early nutritional assessment is essential for preventing pressure ulcers.1 Many nutritional guidelines for preventing pressure ulcers have been published because ulcers tend to develop in patients with malnutrition despite intensive care.1 However, few reports have recommended levels of energy intake needed to heal pressure ulcers. The present study investigated the total nutritional intake of patients with pressure ulcers to determine the level of energy intake needed to heal pressure ulcers.
Methods
Forty patients with pressure ulcers at Nagasaki Medical Center (Nagasaki, Japan) were treated from August 2007 through February 2008. Of these patients, 21 whose wounds improved or healed (improvement group) and 19 whose wounds became worse or did not improve (worse/unimproved group) were eligible for this retrospective study. Primary diseases are shown in Figure 1. In both groups, malignant neoplasms were the most common primary disease.
Patients in the improvement group ranged in age from 22 to 94 years (mean age, 67.4 ± 16.4 years), and patients in worse/unimproved group ranged in age from 51 to 92 years (mean age, 71.7 ± 10.9 years). Pressure ulcer locations are shown in Figure 2. Pressure ulcers developing over the sacrum accounted for about half of all 
ulcers in both groups. The severity of the pressure ulcers at discovery is shown in Figure 3. The severity of the pressure ulcers was similar in both groups, in that only Stage I and Stage II ulcers were discovered; this finding indicates that these pressure ulcers were discovered within the early stage.2 Eight of 21 patients (38%) in the improvement group and 5 of 19 (26%) presented with a Stage I pressure ulcer. Differences in wound severity may account for bias in the study. However, changes in the wounds were investigated (improvement or worsening), and it was assumed that the influence of the primary wound state had little effect on the reported results.
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