Nutrition Benefits Patients Following Trauma

  Reference: Blass SC, Goost H, Tolba RH, et al. Time to wound closure in trauma patients with disorders in wound healing is shortened by supplements containing antioxidant micronutrients and glutamine: a PRCT. Clin Nutr. 2012;31(4):469-475.

  Rationale: After experiencing trauma, patients require extra micronutrients essential to wound healing and managing oxidative stress, as well as glutamine, an amino acid that provides both energy and nitrogen to healing wounds. Supplementing trauma patients with such nutrients has not been studied.

  Objective: Conduct a prospective randomized controlled trial (RCT) to compare effects of glutamine and healing-related micronutrients on wound healing and preventing nutrient deficiency in patients with nonhealing trauma wounds.

  Methods: In the orthopedics/trauma unit of a German university hospital, trauma patients with disturbed wound healing, defined for the purposes of this study as “not closed or persisting secretion within 10 days after trauma or surgery,” gave informed consent before enrollment. Subjects were assigned in randomized blocks to receive either a hospital protein-rich diet without juices fortified by vitamins or other micronutrients (n = 10), or a commercially available granulated glutamine formulation (n = 10) that would add a daily total of 500 mg ascorbic acid, 166 mg α-tocopherol, 3.2 mg β-carotene, 100 mg selenium, 6.6 mg zinc, and 20 g glutamine to their hospital diet.

  Patients confirmed by diary that they took the supplement mixed with foods in 2 daily doses for 14 days with 96% adherence to protocol. Dietary intake of energy, protein, ascorbic acid, α-tocopherol, β-carotene, and zinc was calculated from the German Nutrient Database values for hospital foods consumed using commercial software (Ebis Pro 4.0, University of Hohenheim, Germany) based on subject-reported standardized dietary records monitored on 3 separate days. Injury severity score⁷ was reported at enrollment. Nutrition metabolites, healing, and inflammatory markers were recorded on study days 0 and 14, as were subject body mass index,⁸ general nutritional status (determined using the 4-point Subjective Global Assessment scale),⁹ and risk of malnutrition (estimated using the Nutritional Risk Screening-2002 tool).¹⁰ Time to healing was reported as days from study enrollment to complete healing with no further exudate, infection, or inflammation. Statistical significance of appropriate between-group comparisons was set at P < 0.05.

  Results: Most subjects in the active diet group ingested all 27 packets of the supplemental nutrients. Overall nutrient consumption, metabolites, and inflammatory markers were mainly comparable, with ascorbic acid levels depressed and C-reactive protein levels elevated for most subjects in both groups at baseline. Only α-tocopherol and selenium plasma levels rose more during the study in the active group than in the placebo group. Glutamine levels decreased only in placebo subjects (P = 0.047) while albumin concentrations increased in both groups. Oxygen saturation and blood flow were initially higher for the placebo group, but hemoglobin and vascular endothelial growth factor-A were comparable at baseline and remained so on day 14. Wound healing times were 28 days for the intervention group or 58 days for placebo subjects (P = 0.01), though length of hospital stay, wound temperature, inflammatory markers, and metabolites remained comparable between groups.

  Authors’ Conclusions: Dietary supplementation with antioxidant micronutrients and glutamine accelerated wound closure in trauma patients with disturbed wound healing. Underlying mechanisms of this effect remain unclear.

  Reference: Vidal-Casariego A, Calleja-Fernández A, Villar-Taibo R, Kyriakos G, Ballesteros-Pomar MD. Efficacy of arginine-enriched enteral formulas in the reduction of surgical complications in head and neck cancer: A systematic review and meta-analysis. Clin Nutr. 2014 May 4. pii: S0261-5614(14)00128-9. doi:10.1016/j.clnu.2014.04.020. [Epub ahead of print]

  Rationale: Research has shown that arginine supplements shorten healing time and modulate inflammation and immune responses.

  Objective: Conduct a systematic review to explore if arginine-enriched enteral formulas reduce fistulas, wounds, or other infections, or hospital length of stay (LoS) in patients undergoing surgery for head and neck cancer.

  Methods: Authors searched Medline, CENTRAL, and Trip Databases for the terms “Head and Neck Neoplasms” AND “Enteral Nutrition” AND “Arginine” OR “Immunonutrition.” Randomized controlled trials published in English or Spanish were included in the review if they reported complications of surgery and/or LoS. Study methodology, quality, and heterogeneity were assessed using the Jadad scale. Data were combined when appropriate in meta-analyses reporting Mantel-Haenzel statistics for odds ratios (OR) of clinical effects. Statistical significance was accepted at or beyond the 95% confidence interval.

  Results: Six studies on 397 patients receiving peri- or postoperative enteral nutrition with doses of arginine ranging from 6.25-18.7 g/L were included in the meta-analysis. Enteral arginine formulas were associated with a reduced incidence of fistulas (OR = 0.36, P = 0.039, and a 6.8-day shorter LoS [P = 0.023]). There was no significant reduction in likelihood of wound or other infections. Supplementation with arginine did not increase the occurrence of diarrhea.

  Authors’ Conclusions: Administration of arginine-enriched enteral nutrition led to a significant reduction in fistulas and length of hospital stay in patients undergoing surgery for head and neck cancer.

  The studies summarized above expand the clinical indications that can benefit from nutritional enrichment to patients with nonhealing trauma wounds⁵ or cancer surgery wounds of the head and neck.⁶

  Nutritional supplementation offers an ideal opportunity for patient-centered wound care. Glutamine, arginine, and other essential amino acids are needed to assemble the peptides and proteins involved in wound healing. Zinc, iron, antioxidant vitamins, and other immune-modulating micronutrients also play vital healing roles. It is not surprising that the mechanisms of action lack clarity for micronutrient healing effects in recalcitrant trauma wounds.

  One micronutrient cocktail may not meet all patients’ needs. Different subjects may lack different micronutrients. Standardized nutritional assessments may disclose individual nutrient deficiencies to be addressed. Just as the Braden Scale identifies opportunities for more effective repositioning or support surfaces for patient areas lacking sensation or capacity to move, conscientious early use of nutritional consults and assessments may point to nutritional cocktails customized to meet individual patient needs. Perhaps patient-oriented nutritional interventions could prevent many cases of delayed healing before they become serious.

Laura Bolton, PhD
Adjunct Associate Professor
Department of Surgery
Rutgers Robert Wood Johnson Medical School
New Brunswick, NJ